{"paper_id":"00754d89-f084-490e-b982-dbe7ad9fad20","body_text":"Open Journal of Obstetrics and Gynecology, 2023, 13, 103-107 \nhttps://www.scirp.org/journal/ojog \nISSN Online: 2160-8806 \nISSN Print: 2160-8792 \n \nDOI: 10.4236/ojog.2023.131012  Jan. 31 , 2023 103 Open Journal of Obstetrics and Gynecology \n \n \n \n \nA Rare Case of a Left Ovarian Remnant \nSyndrome Associated with a Symptomatic  \nRight Ovarian Cyst \nNoa Ndoua Claude Cyrille1,2, Metogo Ntsama Junie Annick1,2, Mbarga Jules Anthony1*,  \nBelinga Etienne1,2, Mapina Madola Alice Elvire1 \n1Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon \n2Endoscopy Surgery and Human Reproductive Teaching Hospital, Yaounde, Cameroon \n \n \n \nAbstract \nOvarian Remnant syndrome (ORS) is the presence of residual ovarian tissue \nafter an oophorectomy was performed whether associated with a hysterect o-\nmy or not. We report the case of a 39 -year-old woman with a past surgical \nhistory of total abdominal hysterectomy and left salpingo-oophorectomy with \nan indicat ion of placenta accreta incidentally discovered during a caesarian \nsection. The patient presented with pelvic pain and was diagnosed with ORS. \nShe was successfully managed by laparoscopy with removal of the cyst and \nthe surrounding ovarian tissue, confirme d by histopathological analysis. The \npost operative period was uneventful, and the patient was discharged after 2 \ndays of good evolution. In our context, surgery remains the main treatment \noption, however, other treatment options including radiotherapy or medical \nmanagement need to be considered as either adjunct or main therapy. \n \nKeywords \nPelvic Pain, Ovarian Remnant Syndrome, Laparoscopy \n \n1. Introduction \nOvarian Remnant Syndrome is a rare condition occurring in women who have \nundergone unilateral or bilateral salpingo -oophorectomy with or without hyst e-\nrectomy, resulting from the persistence of ovarian tissue left unintentionally a f-\nter easy or difficult ovarian resection and which becomes functional and/or dy-\nstrophic [1]. In other words, Ovarian Remnant Syndrome is the presence of hi s-\ntopathological proven residual ovarian tissue. At first this syndrome referred to \nonly patients who had undergone b ilateral oophorectomy, but with time and \nHow to cite this paper: Cyrille, N.N.C., \nAnnick, M.N.J., Anthony, M.J., Etienne, B., \nand Elvire, M.M.A. (2023) A Rare Case of a \nLeft Ovarian Remnant Syndrome Associated \nwith a Symptomatic Right Ovarian Cyst . \nOpen Journal of Obstetrics and Gynecol o-\ngy, 13, 103-107. \nhttps://doi.org/10.4236/ojog.2023.131012 \n \nReceived:  December 8, 2022 \nAccepted: January 28, 2023 \nPublished: January 31, 2023 \n \nCopyright © 2023 by author(s) and  \nScientific Research Publishing Inc. \nThis work is licensed under the Creative \nCommons Attribution International  \nLicense (CC BY 4.0). \nhttp://creativecommons.org/licenses/by/4.0/   \n  \nOpen Access\n\nN. N. C. Cyrille et al. \n \n \nDOI: 10.4236/ojog.2023.131012 104 Open Journal of Obstetrics and Gynecology \n \nmore recent studies includes patients with unilateral resection with residual ti s-\nsues confirmed on the side of the previous resection, ovarian remnants can \nre-implant themselves anywhere in the abdominal cavity, inc luding the bladder, \nbowel and ureters [2]  [3]. This syndrome was first described in 1970 by She m-\nwell and Weed [4]  and the first case presented in  the litterature was in 1962 by \nKaufmann [5].  \nThis residual ovarian tissue can grow, form cysts or hemorrhage, may be \nasymptomatic or cause pelvic pain. Risk facto rs associated with incomplete r e-\nmoval of an ovary and the subsequent development of residual ovarian sy n-\ndrome include a history of endometriosis, pelvic inflammatory disease, multiple \nprevious surgeries and multiple pelvic adhesions [6]. The recommended trea t-\nment is surgical removal by laparotomy or laparoscopy [1]  with laparoscopy be-\ning more used nowadays. We report a rare case of a left Ovarian Remnant Syn-\ndrome associated with a symptomatic right ovarian cyst successfully treated by \nlaparoscopy with uneventful post operative course.  \n2. Case Report \nWe report the case of an ovarian Remnant syndrome in a 39 -year-old patient \nwith a history of myomectomy by laparotomy, three caesarean sections, a total \nhysterectomy with left unilateral oophorectomy indicated for placenta accreta \nincidentally discovered during the last  caesarean section and a laparotomy ind i-\ncated for bowel obstruction. She presented with pain in the right iliac fossa of \nprogressive onset, intermittent, with no relieving nor aggravating factors, evol v-\ning over 7 days before her admission, associated with nausea and profuse sweat-\ning, relieved by analgesics. The physical examination on admission revealed a \nrenitent pelvic mass in the right iliac fossa of approximately 80  mm in diameter. \nShe had a computerized tomography (CT) scan of the abdomen and pelvis \nwhich revealed supra -bladder fluid formation with a thick wall (5  mm), oval in \nshape measuring 77 × 71 × 69 mm with intense peripheral enhancement, m e-\ndium-abundance pelvic fluid effusion and left oval ovarian formation with fine \nand regular wall measuring 34  × 36 × 41 mm not raised (\nFigure 1 , Figure 2 ). A \nlaparocystectomy was indicated and the intraoperative findings were a right \novary with a right hemorrhagic cyst. The left ovary was not visualized but we had \n \n \nFigure  1. Left parietal cyst. \nDown \nRight \n\nN. N. C. Cyrille et al. \n \n \nDOI: 10.4236/ojog.2023.131012 105 Open Journal of Obstetrics and Gynecology \n \n \nFigure 2 . Right ovarian cyst. \n \na cyst of the anterior abdominal wall which appeared simple surrounded with \novarian tissue and measuring about 4 cm in diameter. The management consisted \nof the complete removal of the cyst and the surgical specimen sent for anatom o-\npathological examination confirming the presence of ovarian tissue on the left \nspecimen. A cystectomy was performed on the right side. The post-operative fol-\nlow-up was unremarkable, and the patient was discharged after 2 days of favor a-\nble evolution. \n3. Discussion \nThe diagnosis of residual ovarian syndrome begins with a clinical suspicion o b-\ntained through a careful history and knowledge of the syndrome itself. It is su p-\nported by a thorough pelvic examination, imaging investi gations and laboratory \ntests [1]. Dense peri-ovarian adhesions and ovarian enlargement can make it dif-\nficult to identify ovarian tissue, and they are considered predisposing factors for \nthis disease. These two risk factors a re present in severe endometriosis, and it \nwas often found to be the primary indication for initial oophorectomy in p a-\ntients who developed ORS later on in life [5] [6].  \nPatients with this syndrome most often present with symptoms within the \nfirst 5 years after oophorectomy, although some reports have shown that p a-\ntients whose first surgeries dated back more than 20 years ago [5]. Patients most \noften present with pelvic pain and less frequently with asymptomatic pelvic \nmasses [5]. In the largest cohort of patients (183), reported by the Mayo Clinic, \npatients who were treated surgically for this syndrome, presenting symptoms i n-\nclude chronic pelvic pain (84%), dyspareunia (26%), cyclic pelvic pain (9%), dy-\nsuria (7%) and tenesmus (6%) [7] . In pre -menopausal women, pain symptoms \nmay be caused by an increase in the volume of residual ovarian tissue which may \nlead to compression of adjacent structures. Pain can also be due to hormonal \nstimulation ectopic endometriotic implants. In premenopausal patients in whom \noophorectomy is performed unilaterally, the manifestation of pain alone often \ntriggers suspicion [3]. \nImaging can be used to aid in diagnosis. Modalities include pelvic ultrasound, \nCT and MRI. In one study, a complex pelvic mass corresponding to the sy n-\nDown \nRight \n\n\nN. N. C. Cyrille et al. \n \n \nDOI: 10.4236/ojog.2023.131012 106 Open Journal of Obstetrics and Gynecology \n \ndrome was identified in 93%, 92% and 78% of cases by ultr asound, CT and MRI \nrespectively [7]. Similarly in the most recent study, 90% of adnexal mass was de-\ntected by ultrasound [7] which alone seems to be sufficient to  highlight the pel-\nvic mass. It is relevant to mention that FSH and E2 levels can be used for the di-\nagnosis of ovarian remnant syndrome; however, patients are often presenting \nwith symptomatic adnexal masses that will require surgical intervention inde-\npendent of the results. The laboratory investigations are of less use in patients \nwith a history of unilateral oophorectomy. \nThe therapeutic options are medical treatment, radiotherapy but the main \ntreatment remains surgery. The pharmacological approach is gear ed toward \nsuppression of ovarian function and includes oral contraceptives, danazol, and \nGnRH analogs. A recent study used GnRH in a patient without success, which \nconfirms the limited application of the medical approach [3] . Radiation therapy \nhas also been used as a therapeutic approach. The overall results, however, have \nbeen inconsistent. In addition, irradiation without tissue diagnosis has been di s-\ncouraged due to the discovery of malignancy in residual tissues and potential \ndeleterious effects on adjacent tissues [1] [3] [4]. Surgical removal with histolog-\nical confirmation of ovarian tissue remains the reference method [4] . Surgical \nremoval is the main treatment and in addition excision of remaining tissue may \nrequire retroperitoneal dissection [6], ovarian fragments can be difficult to locate \nand reappearance of new fragments is possible. Surgery can be performed by la-\nparotomy, laparoscopy or robotics [5] . The minimally invasive approach has \nbeen the most frequently used, as shown by recent studies with the aim of r e-\nducing the morbidity associated with laparotomy [3] [5] [8] [9]. However, all the \nauthors emphasize the difficulties of this, due to the surgical history and the \nmodification of the anatomical relationships, with a significant risk of visceral \ncomplications, involving the digestive and urinary systems, and vascular co m-\nplications. Price \net al. [9], in an analysis of the litterature,  reported a complic a-\ntion rate of around 16 % to 30% after a laparotomy. Regarding the approach, l a-\nparoscopy can be proposed as first -line treatment, as it reduces the risk of o c-\ncurrence of postoperative adhesion complications compared to laparotomy [ 10] \n[11]. It also leads to lower blood loss and a shorter hospital stay. It has been \nproven that there are increased risks of a woman with BRCA -1/BRCA-2 muta-\ntions developing ovarian cancer over a lifetime ranges from 16% to 54% [3]  and \nin this population if there is a significant risk of developing from the remaining \novarian tissue. If some ovary tissue is left in this population, there is a significant \nrisk of ovarian cancer and clinical treatment is not indicated [3]. \nIn the first series by Nezhat and Nezhat [2]  comprising 13 patients treated by \nlaparoscopic surgery, 9 had a complete improvement of their painful symptoms. \n4. Conclusion  \nOvarian remnant syndrome is a very difficult diagnosis to pose for many physi-\ncians and it may go unnoticed in many situations. High risk factors associated to \nORS include dense pelvic adhesions from multiple prior surgeries, endometr i-\n\nN. N. C. Cyrille et al. \n \n \nDOI: 10.4236/ojog.2023.131012 107 Open Journal of Obstetrics and Gynecology \n \nosis and other conditions which favor the appearance of adhesion leading to \nfunctional ovarian tissue embedding on adjacent tissu e. Surgical excision r e-\nmains the treatment of choice in ORS as malignancy can be associated with the \nremnant tissue especially in high- risk patients with BRCA1 and BRCA2 mut a-\ntions. In many reports literature reports failure in the medical treatment of ORS \nbut in some cases showed to be efficient highlighting the need for research on \nmore therapies. \nConflicts of Interest \nThe authors declare no conflicts of interest regarding the publication of this p a-\nper. \nReferences \n[1] Magtibay, P.M. and Margina, J.F. (2006) Ovarian Remnant Syndrome. Clinical Ob-\nstetrics and Gynecology, 49, 526-534.  \nhttps://doi.org/10.1097/00003081-200609000-00012 \n[2] Nezhat, C., Kearney, S., Malik , S., Nezhat , C. and  Nezhat, F. (2005) Laparoscopic \nManagement of Ovarian Remnant. Fertility and Sterility, 83, 973-978.  \nhttps://doi.org/10.1016/j.fertnstert.2004.12.006  \n[3] Arden, D. and Lee, T. (2010) Laparoscopic Excision of Ovarian Remnants: Retros-\npective Cohort Study with Long-Term Follow -Up. Journal of Minimally Invasive \nGynecology, 18, 194-199. https://doi.org/10.1016/j.jmig.2010.12.002 \n[4] Shemwell, R.E. and  Weed, J.C. (1970) Ovarian Remnant Syndrome . Obstetrics & \nGynecology, 36, 299-303. \n[5] Kaufmann, J.J. (1962) Unusual Causes of Extrinsic Ureteral Obstruction , Part 1. \nJournal of Urology, 97, 319-327. https://doi.org/10.1016/S0022-5347(17)64957-7 \n[6] Kho, R.M. and Abao, M.S. (2012) Ovarian Remnant Syndrome: Etiology, Diagnosis, \nTreatment and Impact of Endoemtriosis. Current Opinion in Obstetrics and Gyn e-\ncology, 24, 210-214. https://doi.org/10.1097/GCO.0b013e3283558539 \n[7] Magtibay, P.M., Nyholm , J.L., Hernandez , J.L. and  Podratz, K.C. (2005) Ovarian \nRemnant Syndrome. American Journal of Obstetrics and Gynecology, 193, 2062-2066.  \nhttps://doi.org/10.1016/j.ajog.2005.07.067 \n[8] Fat, B.C., Terzibachian, J.J., Bertrand, V., et al. (2009) Ovarian Remnant Syndrome: \nDiagnostic Difficulties and Management. Gynécologie Obstétrique & Fertilité , 37, \n488-494. https://doi.org/10.1016/j.gyobfe.2009.03.027 \n[9] Price, F.V., Edwards, R. and Buchsbaum, H.J. (1990) Ovarian Remnant Syndrome: \nDifficulties in Diagnosis and Management. Obstetrical & Gynecological Survey , 45, \n151-156. https://doi.org/10.1097/00006254-199003000-00001 \n[10] Nezhat, F. and Nezhat, C. (1992) Operative Laparoscopy for the Treatment of Ova-\nrian Remnant Syndrome. Fertility and Sterility, 57, 1003-1007.  \nhttps://doi.org/10.1016/S0015-0282(16)55016-X \n[11] Kamprath, S., Possover, M. and Schneider, A. (1997) Description of a Laparoscopic \nTechnique for Treating Patients with Ovarian Remnant Syndrome . Fertility and \nSterility, 68, 663-667. https://doi.org/10.1016/S0015-0282(97)00315-4","source_license":"CC0","license_restricted":false}