A Cystic Surprise: Unearthing Fimbrial Cysts as an Uncommon Source of Abdominal Pain

Fimbrial cysts also known as paraovarian cysts are small and asymptomatic and are occasionally large resulting in pelvic pain. It is difficult to differentiate a fimbrial cyst from an ovarian cyst by imaging; therefore, they are often recognized intra-operatively during laparotomy. This report presents a rare case of a 48-year-old female who presented with the primary complaints of persistent right lower abdominal pain that was intermittently radiating to the back for one year. Clinical findings reported the possibility of twisted right hydrosalpinx but the tumor biomarkers were found to be within the normal range. In addition to this, ultrasound sonography (USG) and magnetic resonance imaging (MRI) revealed a pelvic mass that was indicative of cystic lesions. As the above-mentioned diagnosis was found to be challenging, exploratory laparotomy as a part of surgical intervention and diagnosis was performed along with histopathological investigations that confirmed the existence of fimbrial end cysts on both sides. Fimbrial end cysts represent a rare yet significant cause of abdominal pain; therefore, early recognition, thorough clinical evaluation, and appropriate diagnostic workup are essential for timely intervention and preventing potential complications associated with fimbrial end cysts.

The burden of paraovarian cysts - a case series and review of the literature

Introduction

A paraovarian cyst (POC) is a cyst in the broad ligament or mesosalpinx. Paraovarian cysts have an estimated prevalence of 5-20% amongst the adnexal masses. Despite the high prevalence and availability of advanced imaging modalities, an accurate pre-operative diagnosis of POC is still made in less than 50% of patients.

Case reports

Two females with suspected ovarian torsion underwent laparotomy and had POCs. A 42-year-old hysterectomized female underwent surgery for a suspected POC which turned out to be a mesenteric cyst. Two females underwent laparotomy for suspected mesenteric cysts which turned out to be POCs. A nulliparous female with infertility conceived spontaneously after cystectomy of POC.

Results

Optimal management of an adnexal mass depends on the knowledge of the origin and the exact nature of the mass. No clear-cut guidelines exist for the management of POCs despite their high prevalence. There is a need for further research on this topic to formulate clear-cut guidelines for their management.

Conclusions

Radiologists and gynaecologists need to keep them in mind as differentials for patients with adnexal masses to ensure a correct pre-operative diagnosis in order to achieve an optimal outcome for these females. Gynaecologists need to be aware of the cases which can be managed conservatively and those that need surgery, along with the extent of the surgery required, taking care to protect the ovary at all costs, particularly in benign cases.

Clinical, Imaging, Histological and Surgical Aspects Regarding Giant Paraovarian Cysts: A Systematic Review

Paraovarian cysts (POCs) develop within the broad ligament of the uterus. POCs are considered to be giant when the threshold of 150 mm is exceeded. Clinical signs and symptoms occur as a consequence of the pressure effect on adjacent organs or due to complications. Abdominal ultrasonography, computed tomography or magnetic resonance imaging are useful imaging tools, but most often the exact origin of such voluminous cysts is revealed only by surgical exploration. The review aims to appraise and update the diagnostic, the histological aspects and the treatment of the giant POCs in rare cases. We carried out a systematic search in Medline-PubMed, Google Scholar and ResearchGate electronic databases. Twenty-seven papers fulfilling the selection criteria were included in the review. The data extracted included information about first author, year of publication, country, patient age, size and side of the POCs, symptoms, tumoral markers, imaging methods, preoperative diagnosis, surgical management and histopathological findings. Although not very numerous, all the studies highlighted the low incidence of giant POCs, the impossibility of establishing the origin of the cystic mass by clinical and imaging methods even with advanced technical tools and the low risk of torsion (11.1%). Despite the recognized benign nature of POCs, we found an unexpected high percent (25.9%) of borderline giant POCs. Surgical excision is the only treatment option. Ovarian-sparing surgery was performed in 85.1% of the cases, and minimally invasive techniques were applied in only 42.9% of the patients, which demonstrates the need of a high-level laparoscopic expertise. Knowledge of this pathology, its recognition as a possible etiology of an abdominopelvic cyst, and a higher awareness of the possibility of a borderline histology in giant POCs are required for the proper management of these particular cases.

Minimally invasive management of a giant paratubal cyst in an adolescent female: Case report and review of the literature in the pediatric population

INTRODUCTION

Paraovarian or paratubal cysts both define cysts located between the ovary and the fallopian tube. They are usually benign and frequently occur in the third and fourth decade of life. Paratubal cysts are defined as giant when they exceed the threshold of 150 mm.

METHODS

We report the case of a 15-year-old girl who complained about diffuse abdominal pain since 2 years that was diagnosed with a 196 mm × 90 mm × 267 mm giant paratubal cyst. We furthermore reviewed all the data published on 13 articles, published between 2006 and 2021, concerning giant paraovarian cyst (POC) in pediatric patients.

RESULTS

The giant mass of our 15-year-old patient was removed through a fertility-sparing laparoscopic surgery. Histopathological diagnosis of cystadenofibroma was made up, with no cytologic report of neoplastic cells. The incidence of POC in the pediatric and adolescent population attests around 4%. However, only 12.96% of them are defined giant (larger than 15 cm). Indeed, to the best of our knowledge, only 13 cases of giant paratubal cysts have been reported in adolescents. To accomplish diagnosis and differential diagnosis, accurate history and physical examination are mandatory. In all cases reported in the literature, further instrumental analyses were performed, including ultrasound, CT, and/or MRI scan. International Ovarian Tumor Analysis (IOTA) rules have not yet been validated in the pediatric population. Because of the advantages of the laparoscopic procedures, it is often preferred in pediatric population, also to help preserve as much ovarian parenchyma and salpinx if thought possible. The incidence of malignant adnexal masses in the pediatric population is reported to range from 4% to 9%, accounting for 1% of all pediatric cancers.

CONCLUSION

Giant paratubal cysts in adolescent females are extremely rare and usually benign. A fertility-sparing laparoscopic surgery should be the preferable option whenever possible. Considering the rarity of these conditions, further investigations are needed to exclude the possibility of a malignant evolution.

Fallopian Tube Torsion Secondary to Paraovarian Fimbrial Cyst: A Difficult to Diagnose and a Rare Cause of Acute Abdomen in Adolescent

Fallopian tube torsion secondary to paraovarian or paratubal cyst is a rare gynecological cause of acute abdomen. The condition has no distinctive signs and symptoms. There are no characteristic features on radiological imaging, making preoperative diagnosis very difficult. Paraovarian cysts that are less than 4 cm in size are mostly asymptomatic and found incidentally during a pelvic examination or radiological imaging. It seldom leads to any complications like fallopian tube torsion hemorrhage or rupture. We report a case of an adolescent girl, who presented with severe abdominal pain. Transabdominal ultrasound was suggestive of a cystic structure less than 4 cm in size in the left adnexa. Doppler ultrasound showed normal blood flow to both ovaries. Diagnostic laparoscopy was performed, which revealed a twisted left-sided fallopian tube with a fimbrial paraovarian cyst. Detorsion and paraovarian cystectomy was performed. Although paraovarian cysts are mostly asymptomatic, those arising near the fimbrial end can lead to torsion of the fallopian tube, therefore it should always be considered a possible cause of acute abdomen in adolescent girls with adnexal cysts on ultrasound. Timely surgical intervention can prevent complications such as fallopian tube necrosis, gangrene, removal of the tube, and its long-term implications especially in women of the reproductive age group.

Massive ovarian edema with paraovarian cyst torsion treated with laparoscopic surgery: A case report

Massive ovarian edema is a rare gynecological entity resembling a solid ovarian tumor due to the accumulation of edematous fluid within the ovarian stroma. This condition can be easily mistaken for a neoplasm, resulting in overtreatment by removal of the whole affected ovary. The present study describes the case of a 28-year-old woman who experienced massive ovarian edema with paraovarian cyst torsion treated with laparoscopic surgery. The patient experienced lower abdominal pain lasting for 1 week and visited a local clinic. The ultrasonographic examination revealed two loculated ovarian masses and the patient was then referred to the hospital. Transvaginal ultrasonographic examination revealed a 77.9-mm cystic lesion and a 57.7-mm solid lesion in the left adnexa. A magnetic resonance imaging examination revealed a 55-mm lesion with multiple peripheral ovarian follicles, which was isointense on T1-weighted images and hyperintense on T2-weighted images, and a 75-mm cystic lesion, without a solid component, which was hypointense on T1-weighted images and hyperintense on T2-weighted images in the left adnexa. There were no observed abnormalities of the right adnexa or uterus. Laparoscopic surgery was performed, based on a clinical suspicion of massive ovarian edema with paraovarian cyst torsion. Intraoperatively, a paraovarian cyst was identified in the left adnexa that was twisted 360˚. The size of the enlarged left ovary was reduced to almost normal following the detorsion of the left adnexa. The final diagnosis was that of a massive ovarian edema, which was treated by resecting the paraovarian cyst, while preserving the whole left ovary. The pathological examination of the resected paraovarian cyst revealed a serous cystadenoma. Therefore, the present study suggests that the presence of massive ovarian edema should be taken into consideration when encountering a complex solid ovarian mass with multiple peripheral ovarian follicles, particularly in cases with a history of recurrent abdominal pain.

UNILATERAL SINGLE VAGINAL ECTOPIC URETER WITH IPSILATERAL HYPOPLASTIC AND DEGENERATED KIDNEY ASSOCIATED WITH INFERTILITY IN IBERIAN IBEX (CAPRA PYRENAICA) DOES

This article describes the urinogenital condition of three female Iberian ibexes (Capra pyrenaica-one infertile 3-yr-old adult and two prepubertal animals aged 1 (PP1) and 2 (PP2) yr, respectively, all raised in captivity. All showed constant urinal dribbling, leading to ulcerative dermatitis in the vulvar area. Housed in a stable with other females, the adult did not become pregnant after male contact in either of two consecutive mating seasons. Vaginoscopy and laparoscopic exploration performed on the prepubertal females revealed abnormalities of the vagina and urinary bladder. Ultrasound examination revealed atrophy of the left kidney in the adult female and PP1, and of the right kidney in PP2, with degeneration of the renal pelvis. A paraovarian cyst with hydrosalpinx was also detected in the left oviduct of the adult female. Postmortem analysis of the adult and PP2, which shared a mother, confirmed an extramural single ectopic ureter with vaginal insertion associated with atrophy of the ipsilateral kidney. Though PP1 was officially unrelated to the latter animals, all three might have had a common ancestor in their lineages.

Clinical, radiological, and histopathological analysis of paraovarian cysts

Introduction:

Paraovarian cyst arise from either mesothelium or from paramesonephric remnant. These present as either adneal mass or as an incidental finding. Diagnosis is usually established on ultrasound and it is important to differentiate these from ovarian cyst.

Material and Methods:

The present study is a retrospective analysis of 32 women with a confirmed diagnosis of paraovarian cyst after surgery. The clinical profile, symptoms and radiological findings of these patients were noted from the hospital records. A correlation was made with the surgical findings and the final histopathological diagnosis.

Results:

Only 2 patients were postmenopausal and one case was diagnosed during pregnancy. Ultrasound accurately diagnosed paraovarian cyst in 87.5% patients. 78% paraovarian cysts were found to be simple and none had any malignant change. We reported a higher incidence of cystic adenomatoid tumor in these paraovarian cysts.

Conclusion:

In our study, most paraovarian cysts occur in reproductive age group and present as an adnexal mass. Ultrasound is the diagnostic modality and a paraovarian cyst needs to be differentiated from ovarian cyst. Most of them were simple cysts on histopathology.

Isolated Fallopian Tube Torsion With Fimbrial Cyst In A 10 Year-old Girl Diagnosed By Ultrasound: A Case Report

Torsion of the fallopian tube without the involvement of the ipsilateral ovary is a rare but important cause of acute abdominal pain in women as it is a surgical emergency. Although uncommon, it should be considered as one of the differential diagnosis in female children presenting with acute lower abdominal or pelvic pain. The diagnosis of isolated fallopian tube torsion is difficult pre-operatively and is often made during laparoscopic or surgical exploration because diagnostic features are usually non-specific. In this report, we present a case of isolated fallopian tube torsion with fimbrial cyst in a young female patient diagnosed pre-operatively by ultrasound.

Ultrasound diagnostic of mesonephric paraovarian cyst - case report

Paraovarian cysts are a rare pathology, constituting 10-20% of the adnexal masses. The origin can be represented by paramesonephric ducts (Hydatid cysts of Morgagni), vestiges of mesonephric ducts also represented by mesothelium, or neoplastic (cystadenomas or cystadenofibromas) that are mostly benign. Borderline or malignant paraovarian tumors are encountered less often. This article presents a case of paraovarian cyst in a 37-year-old patient, with a history of 2 pregnancies, completed by cesarean. The patient sought medical attention for an asymptomatic voluminous ovarian cyst, detected in a routine ultrasound scan. Laboratory tests and tumor markers were within normal limits. Transvaginal ultrasound and color Doppler revealed a cystic adnexal mass with 10 cm transonic, smooth, homogeneous content, avascular walls with no internal papillary projections, with a "hyperechoic line" sign of delimitation from the ovarian capsule, mostly visible when the adnexa was mobilized. The diagnostic and curative laparoscopic surgery was successful, followed by a quick recovery. The histopathological exam confirmed the benignity and the origin of the paraovarian cyst. The case was discussed in the context of the literature review concerning this pathology, drawing attention to the real possibility of differentiating ovarian from paraovarian cysts by ultrasound.

Twisted fimbrial cyst (paraovarian cyst): a rare cause of acute abdomen

We present a case of a 22-year-old female who presented with acute abdomen and amenorrhea. Emergency laprotomy was done with a clinical diagnosis of ectopic pregnancy. On laprotomy, twisted fimbrial cysts were found. Thus, although fimbrial cysts are rarely twisted, they should be considered as a cause of acute abdomen in a female of reproductive age group.

Paraovarian cysts of neoplastic origin are underreported

INTRODUCTION

We suspected that paraovarian cysts of neoplastic origin may be underreported. This study was designed to evaluate our data on the pathologic characteristics of cystic lesions located in the paraovarian area and compare them with previous studies that claimed the vast majority of these lesions were simple paraovarian cysts and only few (1.69% to 5%) were neoplastic ones.

METHODS

This is a retrospective analysis of the clinical, surgical, ultrasonographic, and pathologic features of 59 women operated on for cystic paraovarian lesions at our institution from January 2002 to April 2006.

RESULTS

Forty-four women (74.6%) had simple paraovarian cysts, and 15 (25.4%) had benign neoplastic paraovarian cysts (7 cystadenomas and 8 cystadenofibromas). There were no cases of malignant tumor. There was no difference in the clinical presentation of the women with either type of cyst. Preoperative ultrasound examinations (n=50) demonstrated more complex cysts with internal papillary projections in the group with neoplastic paraovarian cysts (41.7% compared with 7.9%, P=0.01). The macroscopic pathologic examinations revealed a significantly increased percentage of gross papillary excrescences in the group of neoplastic paraovarian cysts (10/15, 66.7%) compared with the group with simple paraovarian cysts (3/44, 6.8%, P<0.01). Other pathologic features did not differ between the 2 study groups.

DISCUSSION

Our analysis revealed a higher percentage of paraovarian cysts of neoplastic origin ( approximately 25%) than the figures quoted in most previous reports.

CONCLUSION

Intraoperative inspection for diagnosing the cyst type and more frequent use of endobag devices to avoid spillage of cystic fluid are recommended.