Post-op Puzzle: Deciphering Fallopian Tube Prolapse After Hysterectomy.

Fallopian tube prolapse following hysterectomy is an uncommon condition that can be mistaken for vaginal vault granulation tissue or vaginal vault cancer. We present two cases of post-hysterectomy fallopian tube prolapse that were successfully treated using a combination of laparoscopic and vaginal approaches. Performing hysterectomy combined with routine salpingectomies can prevent fallopian tube prolapse and offer additional protection against tubal and ovarian cancers.

Hysterectomy, Fallopian tube, Prolapse

An uncommon consequence of a hysterectomy is fallopian tube prolapse. This complication can occur regardless of the surgical approach used, though laparoscopic and abdominal hysterectomies are more common than vaginal hysterectomies. Pozzi originally reported this syndrome in 1902. Fallopian tube prolapse is more common in premenopausal women and ranges from 0.01 to 0.5% of all hysterectomies. Cumulative incidence of tubal prolapse after abdominal hysterectomy is 0.06% and 0.5% with vaginal hysterectomy. However, definitive diagnosis is after histology report only [1]. This case report highlights the need for the removal of fallopian tubes during hysterectomy and discusses a combined approach of managing prolapsed fallopian tubes. Case Report Case 1 A 42-year-old P2L2 woman, post-hysterectomy, presented with complaints of vague, dull, aching lower abdominal pain, recurring intermittently for the past three months. She had undergone a non-descent vaginal hysterectomy with bladder repair at a private facility three months earlier due to abnormal uterine bleeding and a uterine fibroid. Intraoperatively, there was a bladder injury that was subsequently repaired. The immediate postoperative period was uneventful, and the patient’s vitals remained stable. On per speculum examination, red fleshy tissue with fimbriae, measuring 1 × 3 cm, was observed protruding from the vault (Fig. 1). On per vaginal examination, no nodularity or induration or any mass felt. After all blood investigations and ultrasonography ruling out any adnexal pathology and obtaining informed consent, the patient was taken for vaginal resection of the fallopian tube under spinal anesthesia. Upon positioning her in lithotomy, visible part of fallopian tube on per speculum examination was excised and appears as coming from pelvic cavity and adherent to vault. Consequently, a decision was made to perform a diagnostic laparoscopy and proceed further. Intraoperatively, fimbrial end of right side fallopian tube was directed toward the vault and it was adherent to it. Left fallopian tube was adherent to lateral pelvic wall due to flimsy adhesions. On right side, part of tube from ovary to vault were excised completely and on left side, salphingectomy was done. The vault appeared healthy with no defects. Histopathology of the sample confirmed normal histology of the fallopian tube. Case 2 A 34-year-old P3L3 woman, post-hysterectomy, presented with complaints of dyspareunia for the past year, accompanied by diffuse, dull aching lower abdominal pain radiating toward back occurring intermittently over the same period. She also reported a history of burning micturition and profuse vaginal discharge on and off for one year. She was a known case of beta-thalassemia trait and autoimmune thyroiditis, for which she was on medication. The patient had undergone an abdominal hysterectomy three years prior at an outside hospital due to heavy menstrual bleeding and fibroids and her postoperative period was uneventful. She had no complaints for first two years after hysterectomy. On examination, the patient’s vitals were stable, and the abdominal examination was normal with no tenderness. Per speculum examination revealed a 2 × 3 cm polypoidal fleshy mass protruding from the vault (Fig. 2) and on per vaginal examination, no induration or pelvic mass felt. Following a thorough evaluation of blood test and ultrasonography, the patient was planned for a combined vaginal and laparoscopic surgical approach. Intraoperative findings indicated a 2 × 3 cm fallopian tube with a fimbrial end protruding through a 1-cm defect in the vaginal vault. On laparoscopy, flimsy adhesions were present over the vault, which were removed. Right fallopian tube was protruding into the vault defect. Whole of the right tube was lifted away from vault and was excised. Left fallopian tube was adherent to peritoneum and was excised. Bilateral ovaries were visualized and found normal. Thus, a bilateral laparoscopic salpingectomy was performed, followed by the closure of the vault defect vaginally. Histopathology reported lymphocytic infiltration in the fallopian tube.

Compared to abdominal hysterectomy, vaginal hysterectomy is associated with a higher incidence of fallopian tube prolapse. The pathogenesis is most likely due to improper closure of the peritoneum and vaginal vault following hysterectomy, and it is more common in younger age group. Several postoperative complications can increase the risk of fallopian tube prolapse, including improper vault closure, increased blood loss during surgery, inadequate hemostasis, use of vaginal drains, postoperative cuff hematoma or abscess, pelvic infections, persistent cough, constipation, uncontrolled diabetes mellitus, low serum protein, and resuming sexual activity before complete vault healing. Additionally, the length of the fallopian tube and defects in the peritoneum or vault are significant factors [2]. The presentation of tubal prolapse can occur as early as two months after hysterectomy or as late as eight years later. The most typical symptoms include lower abdominal pain, dyspareunia, and vaginal discharge [3]. Differential diagnoses for tubal prolapse include vaginal vault granulation, endometriosis, vaginal adenosis, vaginal adenocarcinoma, vesicovaginal fistulas, and ureterovaginal fistulas, all of which need to be ruled out [4]. Histopathological analysis is required for a definitive diagnosis. In doubtful cases, tubal epithelium can be identified using immunohistochemistry with pankeratin antibodies [3]. Surgery is the primary management technique for tubal prolapse. Earlier attempts at cauterization or using silver nitrate showed poor results. The surgical approach can be laparoscopic, vaginal, or a combination of the two. A combined vaginal and laparoscopic method is preferable as it allows for peritoneal cavity lavage and comprehensive exploration of the abdominal cavity. The optimal treatment involves a total salpingectomy and closure of the vault defect [3].

Closing the pelvic peritoneum during vaginal surgeries and performing prophylactic salpingectomy during all hysterectomies can prevent tubal prolapse. The recommended management includes a combination of vaginal and laparoscopic approaches, although a complete vaginal salpingectomy may be sufficient to eliminate the risk of recurrence in cases where adhesions and concurrent pelvic disease are anticipated. With our case report, we aim to raise awareness of this rare but preventable complication of hysterectomy, thus enabling more effective management. Funding None. Declarations Conflict of interest None. Informed Consent We have taken informed consent of patient for taking images and publishing her case as a report without breaching confidentiality of the patient. We have not caused any harm to the patient. Footnotes Chandana Tholu is a Junior Resident; Amruta Choudhary is an Assistant Professor; Prajakta Bhimgade is a Senior Resident; Anita Yadav is an Additional Professor. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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