Ovarian remnant syndrome

[Retained ovarian remnant carcinoma: a case report]

Ovarian remnant syndrome is defined as residual ovarian tissue non intentionally left in place by the surgeon during a bilateral salpingo-oophorectomy. Patients present various symptoms usually including chronic pelvic pain, pelvic mass, bowel obstruction, hydronephrosis due to ureteral compression. We report a case of adenocarcinoma arising in such an ovarian remnant revealed by vaginal bleeding 5 years after total abdominal hysterectomy and bilateral oophorectomy for uterine fibroids. It was regarded as stage IIIc according to the FIGO classification because of common iliac lymph node involvement while there was no ascitis, no peritoneal nor omental implant but a unilateral hydronephrosis induced by extrinsec ureteral obstruction. Complete cytoreductive surgery was achieved including partial bladder and lower ureteral resection with colpectomy, omentectomy, pelvic and para-aortic lymphadenectomy. Paclitaxel-Platinum combination chemotherapy was given for nine cycles.

Ovarian remnant with bilateral duplicate ureters

A 27-year-old woman had a history of acute chronic pelvic pain. She had had a previous salpingo-oophorectomy for an endometrioma. A computerized tomographic scan showed a left adnexal mass. She was known to have bilateral duplicate ureters shown on intravenous pyelogram. She underwent laparoscopy and retroperitoneal dissection of endometriosis with excision of the mass from the pelvic sidewall. The final pathology was consistent with a hemorrhagic corpus luteal cyst.

Frequency and laparoscopic management of ovarian remnant syndrome

STUDY OBJECTIVE

To report the frequency and outcome of laparoscopy in women with chronic pelvic pain and/or pelvic mass who were found to have ovarian remnants.

DESIGN

Cohort study. (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

One hundred nineteen women who had had hysterectomy and oophorectomy.

INTERVENTION

Laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Ovarian remnants were known in 5 and were found intraoperatively in 21 patients (18%). These 26 women had undergone at least one laparoscopy in an attempt to remove the remnants. After the ureter was identified, ovarian remnants were dissected and removed from the retroperitoneum laparoscopically with minimal risk of vessel or visceral injury. There were no intraoperative or postoperative complications and no conversions to laparotomy. In addition to ovarian remnants, adhesions were found in 19 women, endometriosis in 4, and no other pathology in 3. Twenty women had complete relief of symptoms. At follow-up of 1 to 8 years (mean 5 yrs), six underwent repeat laparoscopy for persistent pain; one had recurrent ovarian remnant.

CONCLUSIONS

Ovarian remnant syndrome is not an infrequent complication after hysterectomy and oophorectomy in women with endometriosis.

Ovarian remnant syndrome after laparoscopic oophorectomy

OBJECTIVE

To report the surgical history, clinical characteristics, and operative technique used in patients with ovarian remnant syndrome after laparoscopic oophorectomy.

DESIGN

Observational study.

SETTING

Teaching hospital and private practice office.

PATIENT(S)

Nineteen patients with documented history of unilateral or bilateral laparoscopic oophorectomies with histologic confirmation of ovarian remnants.

INTERVENTION(S)

Operative laparoscopy for resection of ovarian remnants.

MAIN OUTCOME MEASURE(S)

Risk factors and surgical technique contributing to ovarian remnant syndrome.

RESULT(S)

The patients underwent a mean of 4.7 previous surgical procedures (range, two to nine): 12 had bilateral oophorectomy, and seven had unilateral oophorectomy. The infundibulopelvic ligament had been secured with bipolar desiccation in 11 patients, pretied surgical loops in six, and a linear stapler in two. Cystic ovarian remnants were identified by pelvic sonography in 12 women and by computed tomography (CT) scan in one. Six women underwent reoperation, two for ovarian remnants in different sites.

CONCLUSION(S)

With laparoscopic oophorectomy there is risk of ovarian remnant due to improper tissue extraction or misapplication or improper use of pretied surgical loops, linear stapler, or bipolar electrodesiccation on the infundibulopelvic ligament, especially in women with a history of multiple pelvic surgeries, adhesions, or endometriosis.

Management of ovarian remnant syndrome

Ovarian remnant syndrome is a rare condition which develops when functional ovarian tissue which is left in situ after intended bilateral oophorectomy produces clinically significant symptoms, namely chronic pelvic pain and/or dyspareunia. Women with this syndrome may have a pelvic mass palpable on bimanual examination, or visible on transvaginal ultrasound. However, visualization of an ovarian remnant is sometimes difficult because it is small and multiple previous pelvic operations have usually produced dense adhesions and distorted pelvic anatomy. Identification of these remnants may be facilitated by ovarian stimulation. Surgical removal is the optimal treatment, but hormonal suppression of ovarian activity may provide temporary relief of pain.

Ovarian remnant syndrome after laparoscopic hysterectomy and bilateral salpingo-oophorectomy for severe pelvic endometriosis

Ovarian remnant syndrome is a rare complication of total abdominal hysterectomy and bilateral salpingo-oophorectomy (BSO). Ovarian enlargement and dense periovarian adhesions are the predisposing factors. Recurrent ovarian remnant syndrome was associated with recurrence of symptomatic endometriosis in a woman who underwent laparoscopic supracervical hysterectomy and BSO for severe endometriosis and extensive pelvic adhesions. After primary surgery she required five additional procedures for complete resection of all ovarian remnants. Definitive surgery for advanced endometriosis with extensive periovarian adhesions may be complicated by ovarian remnant syndrome and reactivation of the disease. Careful retroperitoneal resection of all ovarian tissue is of paramount importance in preventing the syndrome. This, however, may be a limitation of laparoscopic surgery. The choice between laparoscopy and laparotomy in such cases should be individualized and based on the degree of surgical difficulty and the surgeon's level of experience.

Ovarian remnant syndrome: experience at Jackson Memorial Hospital, University of Miami, 1985 through 1993

OBJECTIVE

Ovarian remnant syndrome has become increasingly recognized as a cause of pelvic pain after extirpative surgery. The purpose of this review was to compare our patient population with those reported in the literature, as well as to address the usefulness of careful retroperitoneal discussion in the surgical management of these patients.

STUDY DESIGN

This article discusses the presentation and surgical management of eight cases of ovarian remnant.

RESULTS

Data were obtained through a retrospective chart review of pathologically confirmed cases of ovarian remnant. Discussion focuses on the surgical management of these cases.

CONCLUSION

In summary, extensive and careful retroperitoneal dissection is typically required to facilitate identification and removal of the ovarian remnant tissue.

Adequacy of laparoscopic oophorectomy

Ovarian remnant syndrome occurs infrequently after oophorectomy, yet when present it can contribute greatly to pelvic discomfort. The syndrome may be difficult to diagnose, identify surgically, and treat without intraoperative or postoperative complications developing. Recently, laparoscopic oophorectomy has been performed with increasing frequency. We assessed the outcome after laparoscopic removal of both ovaries or the sole remaining ovary in 27 premenopausal women. No intraoperative or postoperative complications were identified, and no patients have experienced symptoms consistent with ovarian remnant syndrome. All women had a marked rise in serum follicle-stimulating hormone (FSH) levels (81 to 72+/-5 mIU/ml), and luteinizing hormone (LH) levels (8+/-1 to 37+/-3 mIU/ml) after oophorectomy, and all but one had FSH levels 40 mIU/ml or above. Thirteen women had gonadotropin levels measured after 4 weeks of hormone replacement therapy; all had reductions in FSH levels, but 10 had elevations of their LH levels. These findings indicate that ovarian remnant syndrome occurs infrequently after laparoscopic oophorectomy. In addition, the data suggest a different, nonovarian regulation of gonadotropin secretion.

Recurrent endometriosis following hysterectomy and oophorectomy: the role of residual ovarian fragments

Seven women with recurrent endometriosis after definitive surgery were evaluated. Plasma estradiol, FSH and LH indicated that recurrence was stimulated by residual ovarian fragments in six and pseudopregnancy regimen in one. Surgical treatment in two women was followed in one by hypertrophy of another ovarian fragment and reactivation of endometriosis as demonstrated by serial endocrine and ultrasonographic studies. Three patients responded well to hormonal treatment; one required pelvic irradiation. We conclude that: (1) small ovarian fragments may hypertrophy under increased gonadrotropin stimulation, become functional and stimulate recurrence of endometriosis; (2) resection of one such fragment may be followed by reactivation of another.