{"paper_id":"2e13e45b-8cec-48f7-a31b-082c7e26860c","body_text":"An Obstetrics and Gynecology  \nInternational Journal \n151\nvolume 21, issue 3, July - september 2022\nHJoG 2022, 21 (3), 151-154 | doi: 10.33574/HJoG.0512\nLaparoscopic treatment of a complex adnexal  \nmass of the retroperitoneal space: A case report\nTheodore Liakakos1, Katerina Papakonstantinou1, Michail Panagiotopoulos2, \nDimitrios Papageorgiou 1,2\n1Department of Gynecology, Athens Naval and Veterans Hospital, Greece\n2 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University \nof Athens, Greece\nCorresponding Author\nDimitrios Papageorgiou, Department of Gynecology, Athens Naval and Veterans Hospital, 70, Deinokratous str,  \n11521 Athens, Greece. Tel.: +30 210 7261000, e-mail: mitsakos85@hotmail.com, ORCID: 0000-0003-0160-7755\nAbstract\nComplex adnexal cystic masses in women of reproductive age should be carefully evaluated before the \nfinal diagnosis is set. Adnexal cystic masses are not necessary malignant. On the contrary, they usually refer \nto a benign and not cancerous pathology. A certain benign pathology behind adnexal masses is endome -\ntriosis. Endometriosis occurs in 10-15% of women of reproductive age and presents great diversity both \nin the way it manifests and in its location. We report a case of a multiparous woman of reproductive age \nthat was referred to our clinic due to abdominal and back pain. The imaging examinations revealed a cystic \nmass of the left parametrium that was laparoscopically removed. The histopathology set the diagnosis of \nendometrioma. The aim of our work is to highlight the endometrioma of the retroperitoneal space as part \nof the differential diagnosis of the cystic masses of the parametrium.\nKey words: Endometriosis, adnexal mass, endometrioma, exploratory laparoscopy\nIntroduction\nAdnexal masses have a wide etiology. Both gyne-\ncological and non-gynecological pathologies may \nbe the reason of cystic adnexal masses. Ectopic \npregnancy should be excluded in women of repro-\nductive age. In patients reporting abdominal and \npelvic pain, ovarian cancer must be ruled out and \nCa-125 serum levels should be measured in order \nto exclude different possible pathological entities. In \nwomen of reproductive age, endometriomas should \nalso be part of the differential diagnosis of adnexal \nmasses\n1. Endometriosis is a common benign entity \naffecting 10-15% of females during the reproductive \nage and presents great diversity both in the way it \nmanifests and in its location\n2,3.\nCase Report\nWe report the case of a 45-year-old premenopausal \nmultiparous Caucasian female, with a free medical \nCase Report\n\n152\nliakakos et al\nvolume 21, issue 3, July - september 2022\nhistory, who was referred to the surgical clinic of \nour hospital, due to left abdominal pain and low \nback pain. \nDuring clinical examination signs of inflammation \nor bowel obstruction were absent. Mild pain was \nrevealed at deep palpation of the left lower quadrant \nof the abdomen. Her temperature was normal and \nthe patient did not report any other symptoms.\nOn Computed Tomography (CT) of the abdomen, \na cystic-textured thin-walled formation was found in \nthe left parametrial space with a maximum diameter \nof about 6cm, with a diaphragm, which presents a \nmild outline after intravenous administration of a \ncontrast agent. The cystic mass was expanding at the \nleft parametrium space and was exerting pressure on \nthe left ureter resulting in dilatation of the left renal \npelvis and the upper part of the left ureter. Abdominal \nMagnetic Resonance Imaging (MRI) revealed a lesion \nwith predominantly cystic texture and hemorrhagic \ncontent, measuring 6x6x7cm, at the anatomical \nposition of the left ovary. The lesion presented a \nthickened wall with pathological enrichment after \nintravenous administration of paramagnetic contrast \nmaterial and a reinforced diaphragm, which divided \nthe lesion into two separate parts. These imaging \nfindings were suspicious of possible development \nof primary cancerous pathology. The tumor markers \nwere negative and the rest of the laboratory exami-\nnations had values   within normal range. \nFollowing the above, the patient was referred to \nthe gynecology department of our hospital and an \nexploratory laparoscopy was conducted. Explor-\natory laparoscopy revealed the presence of a large \nendometrial cyst of the left ovary, which extended \nretroperitoneally, as well as a few foci of endometrio-\nsis at the pouch of Douglas. The endometrioma was \nexcised along with the left ovary, laparoscopically, \nafter its detachment from the left ureter and the \nmesosigmoid and was sent for histologic examina-\ntion. Endometriotic lesions of the pouch of Douglas \nwere burned away. Histological analysis confirmed \nthe diagnosis of endometriosis.\nThe patient was discharged from hospital the day \nafter surgery, without any postoperative complica-\ntions and 24 months later she remains asymptomatic.\nDiscussion\nAdnexal masses are common in women of all ages \nand have a variety of etiologies. Ovarian masses are \nthe most common type, appearing in up to 35 % of \npremenopausal women4. These may be asymptomatic \nor present with a number of symptoms that vary \nwidely depending on the underlying etiology. In our \ncase, left abdominal pain and low back pain were the \nreason that the patient sought out medical attention. \nA diagnostic evaluation is required in patients \nwith an adnexal mass, which includes a thorough \nmedical history (menstrual history, onset and type of \nsymptoms, pain characteristics, history of infertility, \ncancer risk factors), physical and pelvic examination, \nlaboratory tests and imaging studies. Transvaginal \nultrasound (TVUS) should be the first-line imaging \nstudy for evaluating an adnexal mass. In our case, \nthe TVUS was omitted as the patient underwent a \nCT and MRI of the abdomen as per the recommen-\ndations of the attending surgeons and she was only \nlater referred to the gynecology department (Figure \n1, Figure 2). The imaging results revealed a complex \nmass, suspicious for malignancy, even though serum \ntumor markers, including CA-125, were within normal \nrange. Furthermore, they revealed that the mass was \nexpanding at the left parametrium space, exerting \npressure on the left ureter resulting in dilatation of the \nleft renal pelvis and the upper part of the left ureter, \nwhich could explain the low back pain of the patient.\nA presumptive diagnosis of the etiology of an \nadnexal mass can often be made based on medi -\ncal history, clinical findings, serum tumor markers \nand the mass characteristics in the imaging studies. \nHowever, a surgical approach is necessary for a de-\n\n153\nlaparoscopic treatment of a complex adnexal mass of the retroperitoneal space\nvolume 21, issue 3, July - september 2022\nfinitive diagnosis of the etiology of an adnexal mass \nbased on the characteristic histologic findings. Our \npatient underwent diagnostic laparoscopy due to \nher clinical symptoms and the suspicious imaging \nfindings. This revealed an endometrioma of the left \novary, which extended retroperitoneally.\nEndometriosis, a common but complex pathologi-\nFigure 2. T1 weighted coronal MRI image showing a cystic \nmass with hemorrhagic content at the anatomical position \nof left ovary. A diaphragm divides the cyst into two parts.\nFigure 1. CT images showing A) left renal pelvis dilatation (blue arrow) and B) left ureter dilatation (red arrow). \ncal entity, is defined as endometrial glands and stroma \nthat occur outside the uterine cavity. Endometriomas \nmay present with a wide range of symptoms depend-\ning its locations and size and laparoscopy has been \nconsidered to be the gold standard evaluating and \ndiagnosing endometriosis2,3. Patients typically pres-\nent during their reproductive years with symptoms, \nmost commonly pelvic pain (including dysmenorrhea \nand dyspareunia), infertility, or an ovarian mass5,6 . \nEndometriomas are often densely adherent to close \nstructures (peritoneum, fallopian tubes, uterus, \nand bowel). In our case, even though the endome -\ntrioma was relatively small (approximately 6 cm \nin diameter), it extended retroperitoneally causing \npain symptoms due to pressure on the left ureter. \nIn cases like that, laparoscory is often challenging \nas it requires careful detachment from the adjacent \nureter and the mesosigmoid. \nConclusion\nEndometriosis should be part of the differen-\ntial diagnosis in cases of patients with pelvic and \nretroperitoneal masses, especially in patients of \nreproductive age. Surgical treatment is often chal-\nlenging and requires deep anatomy knowledge and \nsurgical experience.\n\n154\nliakakos et al\nvolume 21, issue 3, July - september 2022\nDisclosure of conflicts of interest\nThe authors report that they have no conflicts of \ninterest to disclose.\nFunding sources\nThe authors did not receive any type of funding \nfor the present work.\nCompliance with ethical standards\nAll procedures performed in studies involving \nhuman participants were in accordance with the \nethical standards of the institutional and/or national \nresearch committee and with the 1964 Helsinki \ndeclaration and its later amendments or comparable \nethical standards. Informed consent was obtained \nfrom all participants included in this study.\nAuthor contributions\nDP , KP and MP drafted the manuscript. TL super-\nvised the project and revised the manuscript.\nReferences\n1. Biggs WS, Marks ST . Diagnosis and Management \nof Adnexal Masses. Am Fam Physician. 2016 Apr \n15;93(8):676-81. PMID: 27175840.\n2. \nPapageorgiou D, Ivros N, Kalles V, Papapanagiotou \nIK, Papakonstantinou K. Hemorrhagic hydrocele in \nthe canal of Nuck: A rare case of endometriosis. Eur \nJ Obstet Gynecol Reprod Biol. 2021 Sep;264:382-\n383. doi: 10.1016/j.ejogrb.2021.07.011. Epub 2021 \nJul 17. PMID: 34304934.\n3. Papageorgiou D, Prantalos P , Tzavoulis D, Sgouros \nSN, Ivros N, Papakonstantinou K. Massive hemor-\nrhagic ascites associated with extensive severe \nperitoneal endometriosis: A rare case report. Int \nJ Gynaecol Obstet. 2022 Feb 19. doi: 10.1002/\nijgo.14148. Epub ahead of print. PMID: 35182071.\n4. Pavlik EJ, Ueland FR, Miller RW, Ubellacker JM, \nDeSimone CP , Elder J, Hoff J, Baldwin L, Kryscio \nRJ, van Nagell JR Jr. Frequency and disposition \nof ovarian abnormalities followed with serial \ntransvaginal ultrasonography. Obstet Gynecol. \n2013 Aug;122(2 Pt 1):210-217. doi: 10.1097/\nAOG.0b013e318298def5. PMID: 23969786.\n5. Vercellini P , Viganò P , Somigliana E, Fedele L. En-\ndometriosis: pathogenesis and treatment. Nat \nRev Endocrinol. 2014 May;10(5):261-75. doi: \n10.1038/nrendo.2013.255. Epub 2013 Dec 24. \nPMID: 24366116.\n6. Sinaii N, Plumb K, Cotton L, Lambert A, Kennedy \nS, Zondervan K, Stratton P . Differences in char -\nacteristics among 1,000 women with endome -\ntriosis based on extent of disease. Fertil Steril. \n2008 Mar;89(3):538-45. doi: 10.1016/j.fertn-\nstert.2007.03.069. Epub 2007 May 11. PMID: \n17498711; PMCID: PMC2939902.\nReceived 09-05-22\nRevised 17-06-22\nAccepted 21-06-22","source_license":"CC0","license_restricted":false}