CRSLS : MIS Case Reports from SLS

Laparoscopic Management of Disseminated Peritoneal Leiomyomatosis in a Patient Without a History of Myomectomy

Disseminated peritoneal leiomyomatosis (DPL) is a rare condition characterized by multiple peritoneal and subperitoneal nodules composed of smooth muscle cells. Although it has been associated with iatrogenic dissemination following uncontained power morcellation, it may also arise spontaneously. A 46-year-old G1P1 woman with no history of prior myomectomy or morcellation presented with lower abdominal pain and urinary symptoms. Pelvic magnetic resonance imaging (MRI) revealed a lobulated leiomyomatous uterus. She elected to undergo total laparoscopic hysterectomy. Intraoperatively, multiple nodules were unexpectedly identified on the omentum, pelvic peritoneum, and intestinal serosa. Total laparoscopic hysterectomy with bilateral salpingectomy, complete omentectomy, and pelvic peritonectomy was performed. Given the absence of a preoperative diagnosis and prior discussion of risks, a deliberate decision was made to leave the intestinal serosal nodules in situ. The uterus was extracted via contained (in-bag) power morcellation. Histopathological analysis confirmed leiomyoma without atypia. The patient had an uneventful recovery and was discharged within 24 hours. Following incomplete resection, a management plan with periodic imaging surveillance was adopted. One-year follow-up MRI demonstrated stable residual nodules with no features suggestive of malignancy. This report highlights that DPL can occur in patients without a history of morcellation and that preoperative diagnosis remains challenging. Laparoscopy appears to be an effective approach for both diagnostic confirmation and staged management. Decisions regarding extensive resection should consider surgical risk, the high recurrence rate, and the relatively low risk of malignant transformation. Contained power morcellation remains an important preventive strategy.

A Rare Case of Uterine Embryonal Rhabdomyosarcoma

Uterine sarcoma is a rare mesenchymal malignancy, and its preoperative diagnosis presents significant challenges, often resulting in the so-called occult sarcoma following surgery, based on the pathological diagnosis. Embryonal rhabdomyosarcoma of the female genital tract most commonly presents in pediatric patients and occurs in the uterine cervix. A pure uterine embryonal rhabdomyosarcoma presenting in an older adult patient is exceedingly rare. Due to its overall poor prognosis, early recognition of this unusual entity is crucial for patient care. A 57-year-old woman presented with a single uterine mass and intermittent bleeding over the past 4-5 years. Office endometrial biopsies, conducted twice by other providers, reported either normal endometrium or inconclusive results; therefore, she was diagnosed and managed as having uterine fibroids for the past 3 years. Given the high suspicion of uterine malignancy, we counseled the patient with a plan for an abdominal hysterectomy and bilateral salpingo-oophorectomy. Meanwhile, we performed another endometrial biopsy under sedation to obtain an adequate and accurate specimen. This biopsy revealed high-grade malignancy, leading to the diagnosis of uterine embryonal rhabdomyosarcoma following the hysterectomy. She is currently undergoing chemotherapy with docetaxel and gemcitabine. Since there is no reliable laboratory or imaging study for preoperative diagnosis of uterine sarcoma, a high index of clinical suspicion is of the utmost importance to decrease the occurrence of occult uterine sarcoma, which is extremely difficult to differentiate from benign uterine fibroids.

Leiomyoma with Bizarre Nuclei and Hereditary Leiomyomatosis and Renal Cell Carcinoma

Leiomyoma with bizarre nuclei (LBN) is a leiomyoma variant that can be associated with fumarate hydratase (FH) deficiency. Germline pathogenic variants in the A 22-year-old nulligravida female presented with multiple uterine fibroids, heavy menstrual bleeding and pelvic pain, lasting over two years. The patient subsequently underwent laparoscopic myomectomy. Histological analysis of the leiomyomas indicated the presence of bizarre nuclei. Immunohistochemical studies confirmed FH deficiency, characterized by loss of FH expression and overexpression of S-(2-succino)-cysteine (2SC). Genetic testing revealed a likely pathogenic variant (c. 1176_1181delTGCTGT) in the Due to potentially devastating consequence and the occult nature of RCCs, the discovery of LBN should be followed with further investigation for HLRCC.

Laparoscopic Ovarian-Preserving Management of Primary Ovarian Leiomyoma

Extrauterine leiomyomas, including ovarian leiomyomas, are difficult to diagnose given their rarity, especially in the absence of synchronous uterine leiomyomas or a history of a myomectomy. Primary ovarian leiomyomas have historically been managed with oophorectomy, frequently via laparotomy, due to challenges related to preoperative diagnosis and risk stratification of a solid pelvic mass. This is the case of a 27-year-old nulliparous female who presented with 1 episode of abnormal uterine bleeding and mild intermittent left sided pain in the setting of attempting conception. Ultrasound revealed a solid adnexal mass and tumor markers were within normal limits. Laparoscopic mass removal, preserving the ovary, was performed and final pathology resulted as leiomyoma. The patient was able to spontaneous conceive shortly after surgery. This case report highlights the feasibility of laparoscopic ovarian conserving management of primary ovarian leiomyoma following the appropriate clinical workup and patient counseling, with consideration for the patient's age and desire for future fertility.

Uterine Fibroid-Induced Compressive Neuropathy of Lumbar Plexus and Obturator Nerve

Uterine fibroids are the most common gynecologic tumors in reproductive-aged women with a prevalence of up to 80%. Symptoms can range from heavy vaginal bleeding and bulk symptoms to, less frequently, deep vein thrombosis and bowel obstruction. A 32-year-old female patient presented with acute-onset of right groin and knee pain, and difficulty ambulating. A large posterior uterine fibroid was found to be compressing branches of the lumbar plexus, including the obturator nerve. The patient underwent gynecologic evaluation and an urgent laparoscopic myomectomy. Postoperatively, she had significant improvement in neurologic symptoms. She continued physical therapy for residual mild paresthesia and pain with prolonged ambulation. Large pelvic masses such as uterine fibroids should be considered on the differential diagnosis for acute-onset non-gynecologic symptoms such as compressive neuropathy, which require urgent evaluation and possible surgical management.