{"paper_id":"ae3cea2a-9a6c-4bdf-b2cb-0f128a0e692c","body_text":"Review began\n 05/16/2023 \nReview ended\n 05/19/2023 \nPublished\n 05/23/2023\n© Copyright \n2023\nHigashi et al. This is an open access article\ndistributed under the terms of the Creative\nCommons Attribution License CC-BY 4.0.,\nwhich permits unrestricted use, distribution,\nand reproduction in any medium, provided\nthe original author and source are credited.\nLaparoscopic Hysterectomy for Uterine\nAdenomyosis in Patients With a History of Renal\nTransplant: A Case Report and Review of\nLiterature\nTakuro Higashi \n \n, \nShinichi Togami \n \n, \nYuriko Higashi \n \n, \nAkio Tokudome \n \n, \nHiroaki Kobayashi \n1.\n Department of Obstetrics and Gynecology, Kagoshima University, Kagoshima, JPN \n2.\n Department of Obstetrics and\nGynecology, Faculty of Medicine, Kagoshima University, Kagoshima, JPN \n3.\n Department of Obstetrics and Gynecology,\nKagoshima University Hospital, Kagoshima, JPN\nCorresponding author: \nShinichi Togami, \ntogami@m3.kufm.kagoshima-u.ac.jp\nAbstract\nRenal transplantation is a viable treatment option for patients with end-stage kidney disease; however, it\nrequires careful surgical manipulation as the transplanted kidney is placed in the iliac fossa. Herein, we\nreport a case of a 41-year-old female with a history of two renal transplants who presented with\nhypermenorrhea and dysmenorrhea. Computed tomography revealed transplanted kidneys in the bilateral\niliac fossae (right atrophic), and magnetic resonance imaging showed uterine adenomyosis. Three-\ndimensional computed tomography was performed to determine the relationship between the arteriovenous\nvessels, iliac vessels, and ureter of the transplanted left kidney. A diamond-shaped trocar was inserted while\nmonitoring the transplanted kidney. Total laparoscopic hysterectomy and bilateral salpingectomy were\nperformed without any perioperative complications. Immunosuppressants were continued postoperatively.\nLaparoscopic surgery for gynecological diseases can be advantageous and should be considered in patients\nwho underwent renal transplants.\nCategories:\n Obstetrics/Gynecology\nKeywords:\n uterine myoma, three-dimensional computed tomography, uterine adenomyosis, renal transplant,\nlaparoscopic hysterectomy\nIntroduction\nRenal transplantation is considered the most effective treatment option for patients with end-stage renal\ndisease owing to advancements in surgical techniques and immunosuppression \n[1-3]\n.\nAs the transplanted kidney is usually placed in the iliac fossa, pelvic surgical manipulation must be\nperformed carefully. Thus, a total hysterectomy is performed via open surgery \n[4-6]\n. Total laparoscopic\nhysterectomy (TLH) has been increasingly performed to treat benign uterine diseases; however, few reports\nhave documented its application among patients who underwent renal transplantation \n[7,8]\n. We present a\ncase of TLH in a patient who underwent renal transplantation and developed uterine adenomyosis.\nCase Presentation\nA 41-year-old female (gravida 1, para 1) with a history of cesarean section presented to our outpatient\ndepartment for the treatment of uterine adenomyosis. She had undergone renal transplantations at the ages\nof 24 and 30 owing to chronic renal disease caused by immunoglobulin A nephropathy. Her father and sister\nwere the first (right kidney) and second (left kidney) living kidney donors, respectively. She underwent a\nsecond transplant because the function of the previously transplanted kidney deteriorated. Following the\nsecond transplant, the patient’s renal function was preserved by administering immunosuppressants and\nantihypertensives. Two years prior, she experienced severe dysmenorrhea and hypermenorrhea and was\ndiagnosed with uterine adenomyosis at her previous hospital. Conservative treatment failed to improve her\nsymptoms, and she was referred to our department for surgery. Initial physical examination revealed a 15-\ncm surgical wound from the renal transplantations in the lateral aspect of the bilateral lower abdomen.\nAdditionally, a 10-cm cesarean section wound was noted in the midline of the lower abdomen. The patient\nhad an enlarged uterus but normal-sized ovaries. Transvaginal ultrasonography revealed myometrial\nthickening and uterine adenomyosis was diagnosed.\nCervical and endometrial cytology were performed, and no malignant findings were observed. The patient\nhad a normal preoperative serum creatinine level (0.74 mg/dL), estimated glomerular filtration rate (69.1\nmL/min/1.73 m\n2\n), and serum cancer antigen 125 level. Magnetic resonance imaging showed an enlarged\nuterus, thickened myometrium, and adenomyosis. The bilateral ovaries were normal. Computed tomography\n(CT) with contrast showed bilateral transplanted kidneys in the iliac fossae and an atrophic right kidney\n(Figure \n1\n)\n1\n2\n1\n3\n3\n \n Open Access Case\nReport\n \nDOI:\n 10.7759/cureus.39410\nHow to cite this article\nHigashi T, Togami S, Higashi Y, et al. (May 23, 2023) Laparoscopic Hysterectomy for Uterine Adenomyosis in Patients With a History of Renal\nTransplant: A Case Report and Review of Literature. Cureus 15(5): e39410. \nDOI 10.7759/cureus.39410\n\nFIGURE\n 1: Computed tomography with contrast\nComputed tomography with contrast shows the bilateral transplanted kidneys in the iliac fossae. The right\ntransplanted kidney is atrophic (arrow).\nAdditionally, a three-dimensional CT was performed to determine the relationship between the\narteriovenous vessels, iliac vessels, and ureter of the transplanted left kidney (Figure \n2\n).\n2023 Higashi et al. Cureus 15(5): e39410. DOI 10.7759/cureus.39410\n2\n of \n5\n\nFIGURE\n 2: Three-dimensional computed tomography\nThree-dimensional computed tomography reveals the relationship between the arteriovenous vessels of the\ntransplanted left kidney and left iliac vessels and the left ureter of the transplanted left kidney.\nThe patient was hospitalized one day before surgery. She underwent TLH and bilateral salpingectomy for\nuterine adenomyosis 18 months after the initial visit. Immunosuppressive and antihypertensive medications\nwere administered on the morning of the surgery. General anesthesia was administered without epidural\nanesthesia. First, a 5-mm camera port was inserted in the umbilicus, and four ports were inserted to form a\ndiamond shape. The transplanted kidneys were visible in the bilateral iliac fossae (right atrophic) (Figure \n3\n);\nthe retroperitoneal cavity was difficult to expand owing to adhesions.\n2023 Higashi et al. Cureus 15(5): e39410. DOI 10.7759/cureus.39410\n3\n of \n5\n\nFIGURE\n 3: The transplanted left kidney\nThe transplanted left kidney is present in the left iliac fossa (arrow).\nGenerally, the uterine artery is isolated and ligated at its origin; however, given the risk of ureteral and\nvascular injury, isolation and ligation were not performed. Other surgical operations were feasible. The\noperative time was 72 min, and the estimated blood loss was 5 mL. No intra/postoperative complications\noccurred. Postoperative renal dysfunction was not observed. Immunosuppressants and antihypertensives\nwere administered one day postoperatively without drug withdrawal. The patient started walking and eating\non postoperative day 1 and was discharged on postoperative day 5.\nDiscussion\nWe report a case of uterine adenomyosis in a 41-year-old female patient who underwent TLH after renal\ntransplant surgery. In renal transplants, the transplanted kidney is placed in the iliac fossa, and the renal\nvessels are anastomosed with the external or internal iliac vessels. Additionally, if the transplanted kidney is\nlarger than the original, the trocar should be inserted carefully to avoid damaging the transplanted kidney.\nHere, a camera port was inserted through the umbilicus, and the remaining trocars were safely inserted while\nconfirming the location of the transplanted kidney using a camera. In previous reports, transabdominal\nechocardiography has been used to verify the location of the transplanted kidney during insertion \n[8]\n. The\nureter from the transplanted kidney is anastomosed with the bladder. The course of the ureter may vary and\nmay not be appreciated in the abdominal cavity. Moreover, the retroperitoneum expands during\ntransplantation surgery, and adhesion formation is likely. In TLH, the uterine artery is isolated and ligated\nat its origin; however, given the risk of ureteral and vascular injury in this case, isolation and ligation were\nnot performed. The left Okabayashi para-rectal space was unfolded, and the vessels and ureters of the\ntransplanted and original kidneys were dissected externally to process the parametrium safely. Furthermore,\nthe blood vessels and ureters of the transplanted kidney were localized using three-dimensional CT before\nsurgery to ensure safety.\nIn patients who underwent renal transplantation, a hysterectomy is performed via open surgery to address\ngynecological disorders. In a previous report of 42 patients who underwent open total hysterectomy after\nrenal transplantation, 24 (41.4%) developed complications, with the most common being infection (n = 15)\nand blood transfusion (n = 8) \n[6]\n. Adequate perioperative fluid, electrolyte correction, and continued oral\nimmunosuppression are essential in managing postrenal transplant patients. However, perioperative\ncomplications can complicate postoperative patient management. Laparoscopic hysterectomy is a viable\ntreatment option for gynecological diseases and should be considered for patients with a history of renal\ntransplantation owing to its advantages. First, the procedure results in a small wound, with minimal risk of\n2023 Higashi et al. Cureus 15(5): e39410. DOI 10.7759/cureus.39410\n4\n of \n5\n\npostoperative wound infection. Second, the postoperative pain is minimal; therefore, the need for analgesics\nis reduced. Third, hospitalization duration and risk for nosocomial infection are decreased. Finally, the\npatient can rapidly return to oral feeding, and the risk of bowel obstruction is reduced, allowing the\ncontinued use of immunosuppressants \n[7,9]\n. Here, the patient had mild postoperative wound pain, was\ndischarged without any perioperative complications, and immunosuppressive drugs were administered\nwithout withdrawal.\nPatients who undergo laparoscopic surgery have been shown to experience decreased urinary output owing\nto reduced renal blood flow caused by pneumoperitoneal pressure. When the pneumoperitoneal pressure\nexceeds 15 mmHg, the increased renal venous pressure could result in oliguria \n[10]\n. Therefore, the effect of\npneumoperitoneal pressure on renal function should be monitored intraoperatively. Here,\npneumoperitoneum was induced at 8 mmHg for 63 min; however, the intraoperative urine output was\nmaintained at approximately 2.8 mL/kg/h.\nConclusions\nWith the growing number of renal transplantations, the number of laparoscopic surgeries to address\ngynecological diseases in patients with previous renal transplantations is expected to increase. The\nperioperative management of patients with a history of renal transplantation consists of surgical techniques\nthat take into consideration the anatomical changes caused by renal transplantation, as well as the renal\ndysfunction and infections caused by immunosuppression.\nAdditional Information\nDisclosures\nHuman subjects:\n Consent was obtained or waived by all participants in this study. \nConflicts of interest:\n In\ncompliance with the ICMJE uniform disclosure form, all authors declare the following: \nPayment/services\ninfo:\n All authors have declared that no financial support was received from any organization for the\nsubmitted work. \nFinancial relationships:\n All authors have declared that they have no financial\nrelationships at present or within the previous three years with any organizations that might have an\ninterest in the submitted work. \nOther relationships:\n All authors have declared that there are no other\nrelationships or activities that could appear to have influenced the submitted work.\nReferences\n1\n. \nBrunkhorst R, Lufft V, Dannenberg B, Kliem V, Tusch G, Pichlmayr R: \nImproved survival in patients with\ntype 1 diabetes mellitus after renal transplantation compared with hemodialysis: a case-control study\n.\nTransplantation. 2003, 76:115-9. \n10.1097/01.TP.0000070225.38757.81\n2\n. \nWolfe RA, Ashby VB, Milford EL, et al.: \nComparison of mortality in all patients on dialysis, patients on\ndialysis awaiting transplantation, and recipients of a first cadaveric transplant\n. N Engl J Med. 1999,\n341:1725-30. \n10.1056/NEJM199912023412303\n3\n. \nPark S, Kim M, Kim JE, et al.: \nCharacteristics of kidney transplantation recipients over time in South Korea\n.\nKorean J Intern Med. 2020, 35:1457-67. \n10.3904/kjim.2019.292\n4\n. \nChiu IH, Ho WJ, Wu RC, Chao A: \nSuccessful multidisciplinary treatment of uterine serous carcinoma in a\npatient who had previously undergone renal transplantation\n. Taiwan J Obstet Gynecol. 2018, 57:601-4.\n10.1016/j.tjog.2018.06.023\n5\n. \nLiu N, Yang L, Long Y, Jiang G: \nEndometrial cancer in a renal transplant recipient: a case report\n. Open Med\n(Wars). 2020, 15:981-5. \n10.1515/med-2020-0118\n6\n. \nTamhane N, Al Sawah E, Mikhail E: \nTotal laparoscopic hysterectomy in the setting of prior bilateral renal\ntransplant, a case report and review of the literature\n. Surg Technol Int. 2018, 32:139-43.\n7\n. \nChen SY, Huang SC, Sheu BC, Chang DY, Chou LY, Hsu WC, Chang WC: \nLaparoscopically assisted vaginal\nhysterectomy following previous kidney transplantation\n. Taiwan J Obstet Gynecol. 2009, 48:249-53.\n10.1016/S1028-4559(09)60298-9\n8\n. \nKakuda M, Kobayashi E, Tanaka Y, Ueda Y, Yoshino K, Kimura T: \nTotal laparoscopic hysterectomy for\nendometrial cancer in a renal transplantation patient receiving peritoneal dialysis: Case report and\nliterature review\n. J Obstet Gynaecol Res. 2017, 43:1232-7. \n10.1111/jog.13337\n9\n. \nDesai MM, Gill IS: \nLaparoscopic surgery in renal transplant recipients\n. Urol Clin North Am. 2001, 28:759-67.\n10.1016/S0094-0143(01)80031-8\n10\n. \nRichards WO, Scovill W, Shin B, Reed W: \nAcute renal failure associated with increased intra-abdominal\npressure\n. Ann Surg. 1983, 197:183-7. \n10.1097/00000658-198302000-00010\n2023 Higashi et al. Cureus 15(5): e39410. DOI 10.7759/cureus.39410\n5\n of \n5","source_license":"CC0","license_restricted":false}