Outpatient hysteroscopic emptying of a submucosal uterine cystic lesion.

A 39-year-old female, para 4, was admitted to our department after complaining of severe lower abdominal pain for the last year. On physical and gynecological examinations, no pathological finding was detected. Transvaginal sonography (TS) revealed an intramural anechogenic lesion in the uterine fundus 18.2 × 19.6mm in size surrounded by a hyperechogenic ring ( Figure 1 ). This cystic mass was suspected to be a gestational sac, but serum βHCG dosage was negative. Intramural anechogenic lesion (18.2 × 19.6 mm) in the uterine fundus surrounded by a hyperechogenic ring. Tumor markers were within the normal range. An outpatient diagnostic hysteroscopy was performed. The uterine cavity was regular with the exception of an atypical area of vascularization, corresponding to the cystic mass detected on TS. The patient was discharged with a diagnosis of suspicious adenomyosis and was advised to document her pain episodes in a diary. She was scheduled for a repeat TS and CA125 dosage after 3 months. Mefenamic acid was prescribed for further episodes of pain. However, the patient was referred to the emergency room of our department nearly one month later following a severe episode of dysmenorrhea. Repeat TS revealed that the cystic mass had become submucosal. A repeat outpatient hysteroscopy was performed using a 5-mm continuous-flow operative office hysteroscope with a 2.9-mm rod lens (Bettocchi office hysteroscope, Karl Storz, Tuttlingen, Germany). The vaginoscopic approach (without speculum and tenaculum) was used to improve the patient's compliance. Saline solution was used as the distending medium. Neither analgesia nor local anesthesia was administrated to the patient. A translucent lesion apparently blood filled was detected at the uterine fundus. Because the cystic wall was thin, the cyst was emptied by using a flexible needle (1.7 mm and 80 cm length; Karl Storz, Tuttlingen, Germany) introduced through the 5-Fr operative channel ( Figure 2 ). Nearly 5 mL of hematic fluid were drained. Several target biopsies were performed on the cystic wall. The hystopathological result was cystic degeneration of leiomyoma. A TS performed one month later showed that the anechogenic image in the uterus had completely disappeared. At the 3-month follow-up visit, the patient's symptomatology was remarkably improved. Distal tip of the 5-Fr flexible needle (Karl Storz, Tuttlingen, Germany).

Every uterine cystic mass should always be investigated to differentiate a benign from a malignant pathology. 5 Transvaginal ultrasonography, MRI, and blood tests (ie, βHCG and tumor markers) are the main investigations for diagnosing these lesions, avoiding over- or undertreatment. 6 – 8 Hysteroscopy can be a helpful tool both for its diagnostic and therapeutic properties. Moreover, the possibility of performing target biopsies allows a hystopathological diagnosis.

In this report, we have described the possibility of emptying a blood-filled uterine submucosal lesion in an out-patient setting by using a flexible needle inserted through the 5-Fr operative channel of a 5-mm continuous-flow operative office hysteroscope. The index needle is normally used in gynecology to instill intrauterine local anaesthesia under a hysteroscopic view. We adapted it to drain a fluid-filled lesion, identifying a further application for this instrument.

Cystic neoformations of the female reproductive system are very common in the ovarian tissue, while rare in the other organs. The differential diagnosis of the uterine cystic mass includes congenital malformation, leiomyomata cystic degeneration, adenocystic tumor, adenomyosis, echinococcus cyst, and intramyometrial hydrosalpinges. 1 – 4 We report the successful hysteroscopic emptying of a cystic-degenerated leiomyoma with a 5-Fr flexible needle (Karl Storz, Tuttlingen, Germany) in an outpatient setting.