Oestrogen-induced angiogenesis and implantation contribute to the development of parasitic myomas after laparoscopic morcellation

Acute abdomen by red degeneration of a parasitic leiomyoma: A case report and literature review

A 43-year-old woman, with a history of uterine fibroids and multiple myomectomy, presented with acute lower abdominal pain. Computed tomography revealed multiple tumors, including a high-density mass in the left lower abdomen indicative of a parasitic leiomyoma undergoing red degeneration. This uncommon condition is due to acute occlusion, often caused by peripheral venous thrombosis at the fibroid edge. The diagnosis was corroborated by distinctive findings on magnetic resonance imaging and computed tomography. Notably, high signal intensity on T1-weighted images (T1WI) suggested methemoglobin presence due to hemorrhagic infarction, whereas low signal intensity on T2-weighted images (T2WI) indicated deoxyhemoglobin. Symptom improvement followed treatment with analgesics. This case underscores the significance of considering parasitic myomas in the differential diagnosis of intraperitoneal tumors after myomectomy and proposes that vascular torsion from mechanical stress on the mobile mesentery may contribute to red degeneration in such tumors. In this report, we detail the imaging characteristics and clinical progression of red degeneration in a parasitic leiomyoma, emphasizing the importance of this diagnosis in patients with a history of uterine surgery.

Iatrogenic Parasitic Leiomyomas: A Late and Uncommon Complication After Laparoscopic Morcellation

Parasitic leiomyoma (PL) is an extremely rare variant of uterine leiomyomas that occurs outside of the uterus and can often present like intra-abdominal tumors. The aim of this study is to report a case of PL and compare it with current literature. We present a rare case of a 45-year-old female who presented with bloating and spasmodic abdominal cramps for a two-month duration. She had a previous laparoscopic myomectomy six years ago. Transvaginal ultrasound (TVUS) showed solid vascular masses in the pelvis, the largest being 6 cm. Computed tomography (CT) of the thorax, abdomen, and pelvis (CTTAP) revealed further peritoneal masses in the left paracolic gutter suggesting peritoneal distant metastasis. Laparoscopy was completed, and biopsy and histopathological examination confirmed the diagnosis of parasitic leiomyoma. The patient opted for a bilateral salpingo-oophorectomy (BSO) creating iatrogenic menopause. One-year follow-up CT showed a reduction in the size of fibroids. PL can present with vague symptoms, typically nonspecific abdominal pain and cramping. It can often be confused with intra-abdominal tumors. It should be suspected in patients with previous uterine procedures. Histopathological examination is crucial for diagnostic and surgical management.

Port-site implantation of parasitic leiomyoma after laparoscopic myomectomy and its histopathology

Although parasitic leiomyoma could be spontaneous or iatrogenic in origin, port-site implantation of parasitic leiomyoma is an iatrogenic benign sequela of laparoscopic surgery. A 30-year-old, primigravida Japanese woman was referred after unresponsiveness to preoperative gonadotropin-releasing hormone for intramural fibroids. Magnetic resonance imaging showed multiple intramural fibroids and left ovarian endometrioma with no malignant features. Laparoscopic myomectomy with power morcellation and ovarian cystectomy were performed, followed by treatment with a combined oral contraceptive. Seven years after the primary surgery, she underwent abdominal myomectomy for a port-site, and peritoneal recurrence of the leiomyoma and intramural leiomyomas was detected. Microscopic examination revealed that resected specimens from the port-site demonstrated leiomyoma with lesser cell density and more prominent hyalinization than those from the uterus. Therefore, clinicians should counsel patients regarding the risks and benefits of laparoscopy with morcellation versus laparotomy. Further development of techniques for uterine tissues extraction is warranted.

Iatrogenic parasitic myoma and iatrogenic adenomyoma after laparoscopic morcellation: A mini-review

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Parasitic myoma and adenomyoma are two different pathologies.

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Both diseases are iatrogenic conditions developed after morcellation.

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Each entity has different clinical and paraclinical findings.

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The common point of pathogenesis is morcellation.

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Both diseases may be avoided by using in-bag morcellation or by switching to other surgical procedures.

Laparoscopy is widely recognized as a procedure of choice for gynaecological surgery. Myomectomy and hysterectomy are the most frequently performed surgical procedures in gynaecology. A morcellator is often used in myomectomies or subtotal hysterectomies, but morcellation may cause rare complications, such as parasitic iatrogenic myoma or adenomyoma. To improve patient counselling, proper risk estimation as well as risk factor identification should be acknowledged. This article aimed to review the literature on parasitic myoma and adenomyoma and to compare these diseases in terms of clinical, surgical, and prognostic factors. All published literature (case series and case reports) on iatrogenic myoma and adenomyoma was reviewed using PubMed/MEDLINE and ScienceDirect resources. Despite both conditions having an iatrogenic origin, iatrogenic parasitic myoma and adenomyoma are two different entities in terms of clinical manifestations as well as intraoperative particularities, with a common point: iatrogenic complication. A possible solution to avoid these iatrogenic complications is by using in-bag morcellation or switching to another surgical procedure (e.g., a vaginal or abdominal approach). It is concluded that parasitic myoma and iatrogenic adenomyoma are two different iatrogenic morcellator-related complications. In patients with a history of uterus or myoma morcellation who report pelvic symptoms, iatrogenic parasitic myoma or adenomyoma should be considered in the differential diagnosis.

Morcellation-Induced Leiomyomatosis Peritonealis Disseminata: A Rare Case Report

Leiomyomatosis peritonealis disseminata (LPD) is a benign disease characterized by the presence of multiple small nodules on the omentum, parietal, and visceral peritoneum. It corresponds to leiomyoma and often resembles metastases of malignant tumors; however, with favorable prognosis. Here we describe a 46-year-old woman, diagnosed with LPD, to demonstrate the etiopathogenesis of the developed leiomyomatosis following endoscopic extirpation of the uterus with the use of a power morcellator. The patient was operated for diffuse leiomyoma using a power morcellator. Six months later, during a follow-up visit, disseminated tumor nodes on the peritoneum were revealed. Histological and immunohistochemical (smooth muscle α-actin, vimentin, estrogen receptors, progesterone receptors, and Ki67) study confirmed the diagnosis of LPD. As part of the follow-up, certain regression of the tumor nodes was noted against the backdrop of the onset of menopause and the corresponding decline of estrogen levels. Currently, the prognosis is favorable and follow-up is ongoing. Such cases are rare, but the condition is particularly important due to its iatrogenic nature. It has attracted the attention of the Food and Drug Administration (FDA) because power morcellation is probably associated with the risk of spreading suspected cancerous tissue. The existing high risk of iatrogenic LPD formation indicates the need for detailed reporting of all similar clinical cases, including the established pathogenetic and pathomorphological mechanisms of this process to prevent morcellator-related complications.

Estrogen Effects on Wound Healing

Wound healing is a physiological process, involving three successive and overlapping phases—hemostasis/inflammation, proliferation, and remodeling—to maintain the integrity of skin after trauma, either by accident or by procedure. Any disruption or unbalanced distribution of these processes might result in abnormal wound healing. Many molecular and clinical data support the effects of estrogen on normal skin homeostasis and wound healing. Estrogen deficiency, for example in postmenopausal women, is detrimental to wound healing processes, notably inflammation and re-granulation, while exogenous estrogen treatment may reverse these effects. Understanding the role of estrogen on skin might provide further opportunities to develop estrogen-related therapy for assistance in wound healing.

Two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy: An initial experience

OBJECTIVE

To report our initial experience with and the short-term outcomes of two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy (LESS-CLSH).

MATERIALS AND METHODS

A retrospective case study included 40 women who underwent LESS-CLSH from January 2014 to December 2016 at Buddhist Tzu Chi General Hospital. Uterine specimens were extracted through contained manual morcellation with a tissue pouch. The first phase was LESS supracervical hysterectomy and conization of the internal orifice of the cervix. The second phase was transvaginal cervical conization and cylinderization. Women with a uterus diameter of >12 cm, a broad ligament myoma, or severe pelvic adhesion were categorized into a difficult group, and others were categorized into a nondifficult group.

RESULTS

The difficult group required more time and had more blood loss than the nondifficult group. The mean surgical time was 187.2 ± 33.9 and 139.1 ± 20.7 min, and the mean blood loss was 533.3 ± 333.3 and 225.3 ± 168.2 mL in the difficult and nondifficult groups, respectively. The overall visual analog scale (VAS) pain scores at 0-4, 24, and 48 h after surgery were 7.1 ± 1.9, 4.2 ± 1.6, and 2.3 ± 1.5, respectively; no difference in the VAS pain scores, pain relief score, and hospitalization duration was observed between the two groups. Minor surgical complications or adverse events on follow-up were noted. Three months after surgery, the diameter and thickness of the cervix were decreased by approximately 0.5 and 1.0 cm, respectively.

CONCLUSION

LESS-CLSH is a minimally invasive, safe, and feasible approach, even for difficult laparoscopic hysterectomy. Contained manual morcellation enables more controlled specimen removal than morcellation only.

Comment on "Oestrogen-induced angiogenesis and implantation contribute to the development of parasitic myomas after laparoscopic morcellation"

BACKGROUND

The cause of contamination and dissemination of leiomyoma tissue particles and cells in the peritoneal cavity during myomectomy is a challenging issue for both clinicians and researchers. Therefore, the article by Huang et al. recently published in your journal is the subject of this letter.

MAIN BODY

We comment on the role of laparoscopic condition in xenograft implantation and also highlighted the shortcomings of this study. The surgical technique of intramural fibroid enucleation, cell spillage during morcellation and postsurgical hormonal impact on the development of parasitic myomas become evident, while the contribution of CO2 insufflation, the fibroid's nature, mutations and pseudocapsule impacts on angiogenesis are not clear. In addition, an exploration of the exact origin of implanted fragments harvested from the fibroid tissue and their nature might play a significant role in the implantation and the angiogenesis induction ability of xenografts.

CONCLUSION

Taking into account the current literature in the scope of this study, we suggest that the factors involved in development of parasitic myomas can be classified as confirmed and doubtful contributions.

Response to comment on "Oestrogen-induced angiogenesis and implantation contribute to the development of parasitic myomas after laparoscopic morcellation"

According to the literature review, CO2 insufflation on parasitic myoma implantation is not well studied, and we concur that our study is related to "Morcellation-induced parasitic myomas." We did not compare CO2 insufflation to non-insufflation in our study. The reason is the efficacy of gasless laparoscopic myomectomy and morcellation is not well established and this modality is seldom performed. Moreover, the effects of pneumoperitoneum on mesothelial cells and the role of the entire peritoneal cavity as a cofactor in adhesion formation have become well established, the role of CO2 insufflation in the establishment of parasitic myomas has not yet been studied. As such, more in-depth and well-designed studies for the role of CO2 insufflation are needed.

Is Laparoscopic Power Morcellation of Fibroids a Cardinal Sin in 2017?

The diagnosis of an unsuspected leiomyosarcoma after hysterectomy for the treatment of a presumed benign leiomyoma is a rare but highly clinically significant event. In order to facilitate removal of large uterine specimens using a minimally invasive surgical approach, morcellation with extraction in pieces is often performed. In the event of unsuspected malignancy, this may result in abdominal dispersion of the tumor and contribute to poorer survival. Modern surgical innovations always work toward improving minimally invasive strategies. Laparoscopy, rooted in practices for years, supplanted laparotomy for many indications. For extraction of large uteri, morcellation is currently the only way to externalize surgical specimens (myomas, uteri), without increasing the skin opening while allowing to reduce postoperative complications when compared to laparotomy. However, in 2014, the Food and Drug Administration warned against the use of uterine morcellation because of an oncological risk. Some practicing academicians have challenged this recommendation. The incidence of uterine sarcomas is still poorly identified and preoperative diagnostic facilities remain inadequate. The small number of retrospective studies currently available do not reinforce any recommendation. The evaluation of morcellation devices and the improvement of preoperative diagnostic modalities (Imaging, preoperative Biopsy) are being improvised continually so as to minimize the oncological risks. Even during conventional myomectomy, tissue spillage occurs during resection of leiomyoma(s). Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion. Preoperative endometrial biopsy and cervical assessment to avoid morcellation of potentially detectable malignant and premalignant conditions is recommended.

Portomesenteric Vein Thrombosis After Excision of Parasitic Peritoneal Myomas

An enlargement of multiple asymptomatic pelvic masses was detected during a regular checkup of a 39-year-old woman. Twelve years earlier, she had undergone laparoscopic-assisted myomectomy, at which time an uncontained manual extraction of a posterior intramural myoma was performed. This was followed by 2 uneventful cesarean deliveries after spontaneous conceptions. Diagnostic imaging revealed at least 3 abdominal masses, 1 of which received its major blood supply from the inferior mesenteric artery. Gasless single-port laparoscopic excision of the peritoneal masses, was performed along with laparoscopic-assisted vaginal hysterectomy and bilateral salpingo- oophorectomy. The masses were histopathologically diagnosed as parasitic peritoneal myomas. The patient's immediate postoperative course was uneventful; however, on day 6 after surgery, she complained of severe periumbilical abdominal pain and vomiting. Anticoagulant therapy was initiated after hematologic examination revealed an elevated D-dimer level and dynamic computed tomography angiography showed portomesenteric vein thrombosis. Vaginal stump bleeding, which occurred 17 days after the initiation of anticoagulant therapy, was managed conservatively, and there was no recurrence of venous thrombosis in the year after surgery. To avoid significant morbidities and potential mortality when parasitic peritoneal myomas with aberrant neovascularization are excised, attention should be given to the perioperative development of venous thromboembolic events in rare locations.