Vaginal Cuff Endometriosis with Endometrial Hyperplasia: A Rare Cause of Post-Hysterectomy Vaginal Bleeding

Background: In patients who undergo hysterectomy for endometriosis, there is the possibility for recurrence. This article, however, reports a rare instance of vaginal cuff endometriosis in a patient who did not have endometriosis prior to her total abdominal hysterectomy (TAH) with a bilateral salpingo-oophorectomy (BSO). The article describes the methodical surgical technique for safe excision of vaginal cuff lesions, with decreased risks to the bladder, ureters, and bowel. Case: A 53-year-old female presented with postmenopausal bleeding. She had undergone a total TAH/BSO in 2001 for menorrhagia and uterine fibroids. The operative report described an uncomplicated procedure, and pathology was remarkable for inactive endometrium, adenomyosis, small fibroids, and normal ovaries, without evidence of endometriosis. Since then, the patient had used oral estrogen replacement. On presentation, ultrasonography showed no pelvic masses or fluid collections. She did have vaginal cuff granulation tissue and tenderness on bimanual examination. A vaginal cuff biopsy revealed endometriosis with simple hyperplasia without atypia. The patient elected to have laparoscopic vaginal cuff revision with removal of the vaginal cuff endometriosis that was demarcated by injectable dye as a guide. Results: The patient's postoperative recovery was uneventful. No bleeding or pain was noted during a 2-year follow-up period. She was not restarted on estrogen replacement to minimize the risk of recurrence. Conclusions: Laparoscopic vaginal cuff revision with the use of injectable dye to ensure complete excision of cuff endometriosis is a feasible and safe method for the management of symptomatic vaginal cuff lesions following hysterectomy. (J GYNECOL SURG 34:92)