Abdominal wall endometriosis: an overlooked but possibly preventable complication. Taiwan J Obstet Gynecol. 2008;47:42-48. [PMID: 18400581 DOI: 10.1016/s1028-4559(08)60053-4]

Surgical Scar Endometriosis: An Emerging Enigma

Introduction Surgical scar endometriosis is a subtype of extra-pelvic endometriosis that is characterized by the formation of endometrial tissue near the incision site in patients who have previously undergone surgery. In recent times, with the increasing trend in Caesarean sections, the incidence of surgical scar endometriosis has also emerged. This study aims to describe the clinical characteristics and management of surgical scar endometriosis. Methodology We conducted this cross-sectional, observational study over eight years (2015-2022) in a tertiary care centre in Madurai district, Tamil Nadu, India. We conducted this study after acquiring an ethical certificate from the institutional ethics committee (IEC No. VMCIEC/22/2018). In this study, we sampled all women (n = 32) with a pathological diagnosis of scar endometriosis during the study period from hospital records (universal sampling). We searched the data for both general characteristics and lesion characteristics of the patients. The general characteristics include age, body mass index (BMI), parity, mode of delivery, symptoms, and imaging by ultrasound. We have recorded the lesion characteristics of the patient, including location and size of scar endometriosis, layers involved in scar endometriosis, and surgical technique from surgical notes written in the case sheet. The minimum sample size required for this study was 31 study subjects. We entered the data into Excel (Microsoft, Redmond, WA, USA) and analyzed it in SPSS version 21 (IBM Corp., Armonk, NY, USA). We expressed the quantitative variables in terms of mean and standard deviation and the qualitative variables in terms of frequency and percentage. Results The mean age of the study participants was 34 years (range 23-55 years). In our study, 29 patients (90.6%) were multi-para, and only three (9.4%) were nullipara. Among 29 parous women, the majority (25, or 77.7%) had delivered by Caesarean section, while only four (12.5%) delivered by normal vaginal delivery. The surgical procedures preceding the scar endometriosis were predominantly obstetric procedures (87.4%), out of which 25 patients underwent a Caesarean section and only three underwent an episiotomy. The most common presenting symptom of scar endometriosis in our study was cyclical pain in the scar site (90.4%), followed by swelling (81.25%). In 62.5% of patients, the duration between the presentation of surgical scar endometriosis and surgical intervention was greater than one year. Subcutaneous tissue (90.6%) was the most commonly involved layer in surgical scar endometriosis, followed by the rectus sheath (86.2%). The surgical procedure done for scar endometriosis was wide local excision in 78% of patients, and the remaining 22% of patients had wide local excision with mesh repair. Conclusion Cesarean section is an obvious risk factor for surgical scar endometriosis. Clinicians should have a high index of suspicion for surgical scar endometriosis in women presenting with cyclic pain at the scar site. Ultrasound is accurate in diagnosing scar endometriosis. Surgical management by wide local excision with a clear margin with or without mesh repair is the treatment of choice.

Case controlled study for determination of risk factors in abdominal wall endometriosis following a cesarean section

Introduction: Abdominal wall endometriosis (AWE) is the presence of ectopic endometrial tissue in abdominal wall and is most frequently encountered in women with previous cesarean section (CS). The aim of this study is to evaluate the possible risk factors of AWE development. Methods: Women with previous CS and pathologically confirmed AWE were included into the study ( n = 33). Controls ( n = 127) were randomly selected among women who had previous CS and absence of AWE were confirmed by physical examination. Clinical characteristics of the patient and the CS operation preceding AWE were recorded. Results: CS was performed before onset of labor in 87.9% in AWE and in 59.1% of control group ( p = 0.002). The antenatal BMI and weight gain during pregnancy were significantly higher in AWE patients ( p < 0.0001; p = 0.002, respectively). In logistic regression model procedure duration ( p = 0.039; OR = 1083), antenatal BMI ( p = 0.003; OR = 1254), weight gain ( p = 0.002; OR = 1171), and CS before spontaneous labor ( p = 0.021; OR = 5169) were significant parameters for predicting AWE. Discussion: High antenatal BMI, weight gain during pregnancy, and longer duration of operation are all factors effecting subsequent AWE development. However, CS before spontaneous labor is by far the most powerful risk factor for AWE development.

Endometriosis arising in a cesarean section scar: A case report

Introduction and importance

Scar endometriosis is an uncommon variant of extra pelvic endometriosis, which develops at the scar site of previous abdominopelvic surgery and is seen in women during their reproductive period.

Case presentation

We report a 38-year-old female who presented with a nine-months history of a painful ulcerative mass that developed on a cesarean section scar. The mass was removed by a wide excision and confirmed by histology to be endometriosis.

Clinical discussion

Wide surgical resection of ectopic endometriosis is the treatment of choice. It is usually curative and ensures the confirmation of the diagnosis.

Conclusion

Cesarean section scar endometriosis can undergo malignant transformation. This case highlights the need for early detection and treatment.

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Cesarean section scar endometriosis is an uncommon variant of extra pelvic endometriosis

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Wide surgical resection of ectopic endometriosis is the treatment of choice.

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Scar endometriosis can undergo malignant transformation; therefore, early detection and treatment is of a dire need

Clinico-pathological assessment of surgically removed abdominal wall endometriomas following cesarean section

BACKGROUND

Over the past few decades, the rate of Cesarean Section (CS) delivery has been rising rapidly and the prevalence of CS-associated complications including Abdominal Wall Endometriomas (AWE) increases with each additional operation. The aim of this study was to evaluate the clinical characteristics, histopathological diagnostic role and surgical management of post-CS AWE through a retrospective case review.

METHODS

We calculated the incidence of AWE and reviewed all the patients underwent surgical removal of Post-CS AWE during the period of 2012-2018 who were diagnosed, treated and followed up for 2-8 years at our tertiary hospital.

RESULTS

Thirty women with AWE were included. The main symptom in 2/3 of cases was cyclic pain and 4 cases (13.3%) had no symptoms. The mean interval between prior CS and appearance of symptoms was 55.2 months and the mean size of the excised mass was 42 mm. Free surgical margin was less than 9 mm in 9 patients (30%) but no recurrence was recorded among all the studied patients. Pre-operative FNAC diagnosis was performed for only 3 patients (10%) which helped in excluding other potential pathologies. The clinical-pathological agreement value for detection of the nature of the abdominal wall mass was 93.4%.

CONCLUSIONS

Patients with suspected AWE should undergo preoperative cytological biopsy to exclude alternative diagnosis. Wide surgical excision with margin of less than 1 cm could be accepted especially in case of weak abdominal wall. More studies on the post-CS complications; risks, prevention, early detection and proper management should be encouraged.

Atypical Endometrial Hyperplasia Arising in a Cesarean Section Scar: A Mechanism of Malignant Transformation

The incidence of scar endometriosis in Cesarean sections varies between 0.03 and 0.4%. However, the recently increased rate of Cesarean sections worldwide may be causing an increase in occurrence of scar endometriosis. This report presents anatomopathological evidence of an early-stage malignant transformation in endometriotic tissue from a post-Cesarean scar and briefly reviews possible underlying mechanisms. A 40-year-old woman with a body mass index of 42.7 was referred to the gynecological department with recurrent pain and presence of a palpable mass in her Cesarean section scar. She had undergone this procedure 7 years earlier and began experiencing discomfort and pain at the incision site 6 months postoperatively. Surgical treatment was instituted with complete removal of the lesion. Anatomopathological examination revealed endometriotic tissue intertwined with atypical endometrial hyperplasia and fibrosis. At 2 years' follow-up, she was asymptomatic, both clinically and based on ultrasound examination. Endometriotic foci inoculated within an abdominal scar may undergo malignant transformation. Long-lasting abdominal scar endometriosis, in morbidly obese women, requires special attention from the physician.

Endometriosis-associated malignant transformation in abdominal surgical scar: A PRISMA-compliant systematic review

BACKGROUND

Endometriosis-associated malignant transformation in abdominal surgical scar (EAMTAS) is a very rare and aggressive phenomenon. Our current article aims to provide a clinical overview, focusing on risk factors affecting survival.

METHODS

We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review based on prior reviews and case reports regarding the phenomenon published as abstracts in English, from January 1980 to November 2016. Overall, we identified 47 cases, and we included another case from our institution. We further contacted previous investigators to receive updated follow-up regarding their patients. We analyzed the data, focusing on risk factors that might affect overall survival.

RESULTS

All the patients reported in the literature had a uterine surgery, mainly caesarean section. The median time-lag from first surgery to the diagnosis of cancer was about 19 years. Clear-cell carcinoma (CCC) was the most prevalent histology (67%), followed by endometrioid adenocarcinoma (15%). Most of the patients were treated by extensive surgery and chemotherapy and/or radiation. Overall 5 years survival was about 40%. Median overall survival was 42 months (95% confidence interval of [18.7, 65.3]). Although our review is currently the largest in the literature, we cannot draw any statistical significant results due to the limited number of patients reported. According to univariate Cox-regression models, a tendency toward worse prognosis was shown for 3-year disease-free survival clear cell histologic-type (P = .169), and tumor diameter ≥8 cm in nonclear-cell histology, 18 months postdiagnosis (P = .06).

CONCLUSION

EAMTAS is a rare and aggressive disease. It is mostly related to cesarean section scars and is diagnosed many years postsurgery. Clear-cell histology tends to endure from the worse prognosis. The treatment is mainly extensive surgery and adjuvant chemotherapy and/or radiotherapy.

Successful pregnancy after excision of cesarean scar endometriosis with uterovesicocutaneous fistula: A rare case report

Scar endometriosis is an infrequent type of extrapelvic endometriosis. The most common extrapelvic form of endometriosis is cutaneous endometriosis, involving scar tissues occurring after obstetric or gynecologic procedures such as episiotomy, hysterotomy, cesarean section, and even laparoscopic surgery. The clinical presentation of scar endometriosis, i.e., tender swellings, mimics other dermatological and/or surgical conditions and delays the diagnosis. Scar endometriosis very rarely can get complicated with uterocutaneous fistula with a reported incidence of very few cases in world literature. We report a case of a 36-year-old woman presenting with scar endometriosis with complicated uterocutaneous fistula 11 years after her last lower segment cesarean section, managed successfully with laparotomy-fistulectomy and sleeve resection of the bladder with repair followed by successful subsequent spontaneous conception and pregnancy terminated by lower segment cesarean section.

Cesarean scar endometrioma: Case series

AIM: To evaluate endometrioma located at cesarean scatrix.

METHODS: Medical data of 6 patients who presented to our institution with abdominal wall endometrioma were evaluated retrospectively and reviewed literature in this case series. The diagnostic approaches and treatment is discussed.

RESULTS: All patients had a painful mass located at abdominal scars with history of cesarean section. The ages ranged from 31 to 34 and Doppler ultrasonography (US) detected hypoechoic mass with a mean diameter of 30 mm. Initial diagnosis was endometrioma in 4 and incisional hernia in 2 of 6 patients. Treatment was achieved with surgical excision in 5 patients, and one is followed by hormone suppression therapy with gonadotropin.

CONCLUSION: Malignant or benign tumors of abdominal wall and incisional hernias should be kept in mind for diagnosis of endometrioma. Imaging methods like doppler US, computed tomography and magnetic resonance imaging should be used for differential diagnosis. Definitive diagnosis can only be made histopathologically. The treatment should be complete surgical excision and take care against intraoperative auto-inoculation of endometrial tissue in order to prevent recurrences.

Incisional endometriosis: diagnosed by fine needle aspiration cytology

Incisional endometriosis (IE) is a rare entity reported in 0.03–1.08% of women following obstetric or gynecologic surgeries. Most cases reported in literature have appeared after cesarean sections and were often clinically mistaken for hernia, abscess, suture granuloma or lipoma. We hereby report a case of IE following a second trimester hysterotomy, which was diagnosed by fine needle aspiration cytology (FNAC). Our patient was 26 years old, presenting with a mass over anterior abdominal wall, associated with incapacitating pain during each menstrual cycle. FNAC showed epithelial cells, stromal cells and hemosiderin laden macrophages. Based on the typical history, clinical and cytological features, the diagnosis of IE was established. Wide surgical excision was done and the resulting rectus sheath defect was repaired. Patient was followed for 6 months during which time she was symptom free. This article also reviews the spectrum of cytological features and the rare possibility of malignant transformation that can occur in IE.

Fine-needle aspiration cytology of scar endometriosis: study of seven cases and literature review

Endometriosis is defined as the presence of endometrial-like glands and stroma outside the uterine endometrial lining. Endometrial tissue has also been identified in numerous surgical or procedure scars, including cesarean section and laparoscopic trocar tract. A prospective study was conducted at Maternidade-Escola Assis Chateaubriand, Faculty of Medicine, Federal University of Ceara, Brazil in seven patients with abdominal wall mass pathologically proven as scar endometriosis from January 2004 to December 2008. All cases were submitted to fine-needle aspiration cytology (FNAC). Age ranged from 21 to 42 years old (mean: 30) with parity ranging from 0 to 3 (mean: 1.4). The preceding history of pelvic procedures was miomectomy (1 of 7), cesarean section (3 of 7), and diagnostic laparoscopy (3 of 7). The complaints occurred about 18 months after the surgical proceeding. The FNAC findings were endometrial-like epithelial cells (6 of 7) and stromal cells (6 of 7); decidualization occurred in 2 of 7 cases. Hemosiderin-laden macrophages were present in all cases. FNAC is a fast and accurate method to make the diagnosis before the surgery, avoiding errors in the approach of the abdominal wall endometriosis' scars.

Appearance of abdominal wall endometriosis on MR imaging

OBJECTIVE

Abdominal wall endometriosis (AWE) is defined as endometrial tissue that is superficial to the peritoneum. AWE is often difficult to diagnose, mimicking a broad spectrum of diseases. The aim of this study was to describe the appearance of AWE on magnetic resonance (MR) imaging.

METHODS

We present ten patients with AWE (12 lesions) in which MR imaging was used for diagnosis. MR imaging included T2-weighted imaging and T1-weighted imaging with fat suppression. To assess the value of diffusion-weighted imaging (DWI) in endometriosis, four patients underwent additional DWI. The apparent diffusion coefficient (ADC) was calculated using b values of 50, 400, 800 and 1,200 s/mm(2).

RESULTS

In most cases, the lesion was located ventral or dorsal to the aponeurosis of the rectus oblique muscle (n = 6) or in the rectus abdominis (n = 5). MR of AWE lesions showed isointense or slightly hyperintense signal compared with muscle on T2-weighted images and showed isointense or slightly hyperintense signal compared with muscle on T1-weighted images with foci of high signal intensity, indicative of haemorrhage. The mean ADC value of AWE was 0.93 x 10(-3)/mm(2)/s.

CONCLUSION

MR imaging seems to be useful in determining the location and depth of infiltration in surrounding tissue preoperatively.