{"paper_id":"1665a985-6d2f-460f-bc8e-6de216b6de26","body_text":"Gynecol Surg (2004) 1:45–47\nDOI 10.1007/s10397-003-0003-y\nCASE REPORT\nVasilios Tanos\nThe use of trans-vaginal laparoscopy in ruling out pelvic malignancy:\na case report\nPublished online: 14 January 2004\n/C23 Springer-Verlag Berlin / Heidelberg 2004\nAbstract Trans-vaginal laparoscopy (TVL) was per-\nformed in a patient at high risk for ovarian cancer (OC).\nDuring a routine check-up vaginal sonography and color\nDoppler studies revealed neoangiogenesis with low\nresistance in both sides. The left ovary was slightly\nenlarged, and the increased blood vessels were seen in the\ncenter and in the periphery of the left ovary. The patient\nwas placed in the lithotomy position after sedation, and a\nveres needle was inserted in the posterior vaginal vault. A\ntrocar followed, and warm normal saline was injected in\nthe pelvis. The needle was removed, and a telescope was\nintroduced, connected to a light source and a monitor.\nExcellent visualization was achieved, and the average\ntime of TVL was 30 min. Dilated veins in both adnexa\nand pelvic tissues due to severe obesity were visualized.\nTVL helped in establishing the diagnosis, saving this\npatient from an unnecessary laparoscopy or laparotomy.\nKeywords Ovarian cancer · Trans-vaginal laparoscopy\nIntroduction\nThe high-risk patients for developing ovarian cancer are\npostmenopausal women and patients with BOC syndrome\n[1]. Vaginal sonography accompanied by color Doppler\nstudies and serum Ca125 as a screening measure on\nasymptomatic patients has failed to reduce OC mortality\nsignificantly [2]. Similarly, patients diagnosed with\novarian lesion after imaging most of the times have to\nundergo unnecessary operations to rule out ovarian cancer\n(OC). According to the latest reports, for every seven\npostmenopausal women identified with abnormal ultra-\nsound (US) and/or elevated Ca125 and undergoing\nlaparoscopy/laparotomy, only one had OC [1, 2, 3].\nThe great majority (>95%) of women with suspected\novarian cancer are usually postmenopausal women with\nabnormal pelvic sonography. When a pelvic mass is\nfound, computerized tomography and/or magnetic reso-\nnance imaging and serum Ca125 usually follow to help\nwith the diagnosis [4]. However, in more than 70% of the\ncases, benign pathology is reported. As a result, many\nunnecessary laparotomies or laparoscopies are performed\nin fear of ovarian cancer [3].\nTrans-vaginal laparoscopy (TVL) using a 2.8-mm-\ndiameter telescope is a new method that is primarily used\nto diagnose infertility problems such as endometriosis,\npelvic adhesions and other pelvic pathology with great\nsuccess [5, 6, 7]. TVL was performed on a patient with\nsuspected ovarian/pelvic pathology visualized by ultra-\nsound, suggesting ovarian cancer. It was of a great help in\nestablishing the diagnosis, saving the patient from under-\ngoing a more invasive procedure.\nCase report\nThe patient was a 60-year-old female, married with two children,\nwho was obese (110 kg), but generally healthy. She had gained\n15 kg in the last 14 months. During a routine check-up, vaginal\nsonography and color Doppler studies revealed neoangiogenesis\nwith low resistance on both sides. The left ovary was slightly\nenlarged, and the increased blood vessels were seen in the center\nand in the periphery of the left ovary (Fig. 1A). In the right adnexa,\nincreased vascularity with low resistance flow was seen adjacent to\nthe right ovary (Fig. 1D). When TVL was performed varicose veins\nwere visualized in both ovaries (congested ovaries), more promi-\nnently in the left ovary (Fig. 1B, C) and in the right fibria (Fig. 1E,\nF). The warm normal saline used to visualize the pelvis was\ncollected and sent for cytology. Normal cytology was reported. The\netiology of these findings seems to be the increased peripheral\nestrogens due to the increased body mass index. The TVL was\nuneventful, and the patient was discharged home after 2 h.\nV. Tanos ( ))\nDepartment of Gynecological Oncology,\nEvagelistria Medical Center,\nP.O. Box 25441, 1309 Nicosia, Cyprus\ne-mail: tanosv@spidernet.com.cy\nTel.: +357-22-673340\nFax: +357-22-673305\n\nDiscussion\nThe anatomical position of the ovaries and the delayed\nonset of symptoms in ovarian cancer are the main reasons\nfor the high mortality rate. The application of vaginal\nsonography alone or in combination with Ca125 does not\nseem to reduce the OC mortality rate significantly, while\nit increases the number of unnecessary laparoscopies/\nlaparotomies [2, 3]. Hence, the need for a better method\nof detection of OC at an early stage is necessary. At this\nstage, the application of an OC detection screening\nprogram looks remote. Studies have shown that the\napplication of vaginal sonography and Ca125 serum\nlevels is more efficient for this special group of patients\n[2], but, again, in order to establish the diagnosis at least\nwith a biopsy implies an invasive procedure with\nanesthesia with a substantial financial cost and psycho-\nlogical distress for the patient.\nImaging procedures like 3D-ultrasound, color Doppler\nstudies, computerized tomography scanning or magnetic\nresonance imaging give excellent resolution and are very\nhelpful in identifying an ovarian lesion. However, for the\nfinal diagnosis an open biopsy is still necessary. Recently,\nthe fractal dimensions of outlines of sonographically\ndepicted solid components in 160 ovarian tumors were\nmeasured using a box-counting method. This study\nshowed that the surface of solid components in cystic\nepithelial ovarian cancers has a fractal structure and may\nrequire different treatment strategies [8]. Of course, there\nis still the question whether ovarian cancer initiates from\nthe ovarian core or from the surface. The two basic\ntheories generally accepted by the majority of gynecol-\nogists worldwide are: (1) the theory of “incessant\novulation,” i.e., the switching on and off of cell growth\ninducing the potential of uncontrolled growth [9] and (2)\nthe theory of “ovulatory age,” the more ovulations the\ngreater the risk of developing ovarian cancer [10]. Both\ntheories support the fact that OC initiates from the ovarian\ncortex surface. The chance to depict ovarian lesions at a\nvery early stage, before even stage I, by imaging\ntechniques has not been tried because it seems unrealistic.\nRecently, Leeper et al. reported an increased frequency\nof occult ovarian carcinomas after prophylactic oopho-\nrectomy specimens in high-risk women and concluded\nthat (1) the fallopian tubes and the ovaries should be\nentirely submitted for histopathological serial sections\nand (2) that laparoscopy and laparotomy are the surgical\nmodalities of choice to allow inspection of the peritoneal\nsurfaces at the time of prophylactic oophorectomy and\ncollection of fluid for cytologic evaluation [11].\nUnder these circumstances TVL seems to be an\nattractive method for examining the adnexae, but also\nthe whole pelvis of women at high risk of OC. In TVL the\ntissues inspected are floating in normal saline, providing\nbetter and more accurate visualization since pelvic lesions\ncan be demonstrated that could not be identified by\nlaparoscopy or laparotomy. Brosens et al. in 2001\nreported the diagnosis of micro, filmy adhesions and\nendometriosis foci within the fallopian tubes and the\novaries that could not be diagnosed by laparoscopy [5].\nThe problem of spreading the disease after biopsy of a\nlesion suspected of OC during TVL is of primary\nimportance. However, frozen section or a switch to\nlaparotomy in these cases can be an option. In this case\nreport we can conclude that the method of trans-vaginal\nlaparoscopy enabled direct visualization of the ovaries\nand pelvis, whereby the cytology obtained excluded\npelvic/ovarian malignancies.\nFig. 1 A patient with bilateral\nadnexal neoangiogenesis. A\nLeft ovary with low resistance\nblood flow. B, C Arrows show\nthe varicose veins formed on\nthe left ovary. D Right ovary\nwith low resistance flow on its\ntop, which the TVL eventually\nshows as the right fibria cov-\nered with varicose veins. E\nPanoramic view of the right\nsaplings fibria. F Close-up view\nof the right fibria. Arrows show\nthe distended veins\n46\n\nReferences\n1. DiSaia PJ, Creasman WT (2002) Epithelial ovarian cancer. In:\nDiSaia PJ, Creasman WT (eds) Clinical gynecologic oncology.\nMosby, St Louis, p 289\n2. Jacobs IJ, Skates SJ, MacDonald N, et al (1998) Screening for\novarian cancer: A pilot randomized control trial. Lancet\n353:1207\n3. Rosenthal A, Jacobs I (1998) Ovarian cancer screening. Sem\nOncol 25:315\n4. Jacobs I, Davies AP, Bridges J, et al (1993) Prevalence\nscreening for ovarian cancer in postmenopausal women by CA-\n125 measurement and ultrasonography. BMJ 306:1030\n5. Brosens I, Campo R, Gordts S (1999) Office hydrolaparoscopy\nfor the diagnosis of endometriosis and tubal infertility. Curr\nOpin Obstet Gynaecol 11:371\n6. Gordts S, Campo R, Brosens I (2000) Office transvaginal\nhydrolaparoscopy for early diagnosis of pelvic endometriosis\nand adhesions. J Am Assoc Gynecol Laparosc 7:45\n7. Moore ML, Cohen M (2001) Diagnostic and operative trans-\nvaginal hydrolaparoscopy for infertility and pelvic pain. J Am\nAssoc Gynecol Laparosc 8:393\n8. Kikuchi A, Kozuma S, Sakamaki K, Saito M, Marumo G,\nYasugi T, Taketani Y (2002) Fractal tumor growth of ovarian\ncancer: sonographic evaluation. Gynecol Oncol 87:295\n9. Fathala MF (1971) Incessant ovulation—a factor in ovarian\nneoplasia. Lancet ii:163\n10. Cassagrande JT, Louie EW, Pike MC, Roy S, Henderson BE\n(1979) Incessant ovulation and ovarian cancer. Lancet ii:170\n11. Leeper K, Garcia R, Swisher E, Goff B, Greer B, Paley P\n(2002) Pathologic findings in prophylactic oophorectomy\nspecimens in high-risk women. Gynecol Oncol 87:52\n12. Brosens I, Gordts S, Campo R (2001) Transvaginal hydrola-\nparoscopy but not standard laparoscopy reveals subtle endo-\nmetriotic adhesions of the ovary. Fertil Steril 75:1009\n47","source_license":"CC0","license_restricted":false}