Leyomiomatosis peritonealis disseminata associated with ovarian endometriosis in a patient submitted to hysteroscopic myomectomy

OBJECTIVE: To describe laparoscopic management of a case of leyomiomatosis peritonealis disseminata associated with ovarian endometriosis. DESIGN: Surgical video article. SETTING: Academic hospital. PATIENT: We present a case of a 30-year-old woman referred to our clinic for abdominal and pelvic pain and dyspareunia. A hysteroscopic myomectomy was reported as previous surgical history. At ultrasound examination, a left ovarian cyst of 4 cm suspected for typical endometrioma and a mild hydroureteronephrosis of left kidney were revealed. The patient was scheduled for laparoscopic surgery. INTERVENTIONS: During laparoscopy, multiple nodules were found simulating widespread metastases involving colon, small bowel, omentum, right diaphragmatic dome, gastric surface, vesico-uterine area and abdominal peritoneum. Several biopsies and a peritoneal washing were performed, suspecting a peritoneal carcinomatosis. The histological frozen section examination revealed a possible benign disease, requiring further immunohistochemical study that diagnosed leiomyomatosis peritonealis. A second laparoscopy was then performed after one month. Enucleation of the left ovarian endometriotic cyst with classic stripping technique was performed. The left ureter was compressed by a fibrotic nodule of 5 cm that was isolated and removed. Operating time was 80 minutes. The postoperative course was uneventful and the patient was discharged on postoperative day 2. MAIN OUTCOME MEASURES: Description of a case of leiomyomatosis peritonealis disseminata in a patient with no previous history of intra-abdominal morcellation. RESULTS: The removal of the left ovarian endometriotic cyst and the periureteral nodule was successfully performed. The patient reported good health conditions without hydroureteronephrosis at six months follow up visit. CONCLUSIONS: Leiomyomatosis peritonealis disseminata is a rare clinical disorder characterized by proliferation of nodules, consisted by smooth muscle cells. The association of this condition with endometriosis has been described in other studies. Despite several medical therapies have been proposed (chemotherapy, aromatase inhibitor, gonadotropin-releasing hormone agonist), surgical excision remains a good option, frequently performed for symptoms palliation. Laparoscopic approach might be considered the procedure of choice in case of symptomatic women with leiomyomatosis peritonealis disseminata.