Pre-operative treatment of an abdominal wall endometrioma with nafarelin acetate. Case report

[Abdominal wall endometriosis after caesarean section: report of fifteen cases]

OBJECTIVE

Parietal endometriosis is an uncommon pathology. It can occur on all the scars, most often after a surgical procedure with hysterotomy. Surgical scar endometriosis following caesarean section has an incidence of 0.03 to 0.4%.

PATIENTS AND METHODS

This retrospective study reviewed all the cases of parietal endometriosis seen during a 7-year period in the department of visceral surgery of the Armentière's hospital center. A pathological analysis has confirmed each lesion retained.

RESULTS

15 women were treated during this period. The mean age is 32 years. All the women have one or two antecedents of caesarean with Pfannenstiel's laparotomy. The interval between the caesarean and the appearance of the first symptoms is on average of 5 years and 11 months. Only 66.6% of cases presented the classical symptoms with cyclic pain. For 66.6% of patients, the diagnosis of parietal endometriosis was suspected before the treatment. The treatment is a surgical one with exeresis for all the women. In 13.3% of the cases, the lesion is pre aponeurotic. In 46.6% of the cases, it overgrows the rectus abdominis muscle, in 33.3% of the cases the external abdominal oblique and at last a lesion overgrows the transversus abdominis and one is in an inguinal localization. The mean size of lesions is 2.48 cm. We have not notified complications and no recurrence was noted.

DISCUSSION AND CONCLUSION

The local endometrial cell transplant is the most likely mechanism to explain the physiopathology of parietal endometriosis. The classical symptoms associate a painful swelling and cyclic pain related to the menstrual period, but all of these symptoms are not always associated. The contribution to the diagnosis of the imaging studies is weak. The surgical treatment has to be sufficiently wide to avoid all recurrence. No means of prevention has proved its efficiency. In 26.6% of cases the parietal endometriosis is associated to pelvic endometriosis. This localization is more often asymptomatic. Then the realization of a laparoscopic exploration is not indicated immediately.

Abdominal wall endometriomas near cesarean delivery scars: sonographic and color doppler findings in a series of 12 patients

PURPOSE

To describe the sonographic and color Doppler features of endometriomas of the abdominal wall arising near cesarean delivery scars.

METHODS

Twelve women (mean age, 31 years; range, 22-42 years) underwent sonographic and color Doppler examination of the abdominal wall with high-frequency probes for the presence of painful nodules near cesarean delivery scars, cyclic or continuous lower abdominal pain, or both.

RESULTS

All patients had undergone at least 1 cesarean delivery before admission (mean, 4.1 years; range, 2-12 years). A typical clinical presentation (ie, mass and cyclic pain and swelling during menses) was recorded in 6 cases. Sonography disclosed all subcutaneous nodules (mean size, 28.1 mm; range, 7-50 mm). Common sonographic features included (1) a hypoechoic inhomogeneous echo texture with internal scattered hyperechoic echoes; (2) irregular margins, often spiculated, infiltrating the adjacent tissues; and (3) a hyperechoic ring of variable width and continuity. At color Doppler examination, a single vascular pedicle entering the mass at the periphery was shown in 7 cases. Abundant intralesional vascularization was shown in 3 cases with diameters of greater than 3 cm, whereas no vascular sign could be detected in 2 lesions smaller than 15 mm. All patients underwent wide surgical excision, and pathologic examination disclosed endometrial tissue in all of them. No relapses were recorded at clinical and sonographic follow-up (4-23 months).

CONCLUSIONS

Sonographic and color Doppler findings, when properly combined with clinical data, may substantially contribute to the correct preoperative diagnosis of abdominal wall endometriomas.

Abdominal wall endometriomas

Endometriosis is a condition in which uterine mucosal tissue is located outside the uterus. Endometriosis may be pelvic or extrapelvic. The term endometrioma is used when endometriosis appears as a circumscribed mass. Abdominal wall endometriomas are usually a secondary process in scars after surgical procedures. A retrospective study of abdominal wall endometrioma, from March 1992 through April 1999 at our institution was done. The mean age of the patients was 28.4 years. Twelve of these reported cases were secondary to previous surgery. One patient presented primarily with an abdominal wall mass without previous surgical history. The most common presentation was an abdominal wall mass associated with pain during the menstrual cycle. Endometrioma was considered as a differential diagnosis in seven patients. All patients underwent surgery. Along with the literature review on endometrioma, the importance of considering it in the differential diagnosis for patients of child-bearing age is discussed.

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.