A 41-year-old female presents for evaluation of painful, prolonged, heavy menstrual bleeding. She reports bleeding is severe, necessitating multiple transfusions over the past 11 years. Anemia is also reported, with hemoglobin levels having dropped as low as 6 g/dL. Symptoms have been nonresponsive to oral contraceptive therapy. Medical history is significant for acid reflux, type II diabetes mellitus, and morbid obesity. Obstetric and gynecologic history includes two dilation and curettage (D&C) procedures, a laparoscopic right ovarian cystectomy, and one Cesarean section. The patient notes persistent right lower quadrant pain since her cystectomy four years prior. She has no history of abnormal pap smears and family history is negative for gynecologic malignancies.
Bimanual exam is significant for an anteverted uterus of eight-weeks size. No abnormalities of the external genitalia, vagina, or cervix are noted. Adnexa are nontender and non-enlarged on palpation.
Possible diagnoses including intramural uterine leiomyoma (based on mild uterine enlargement) and endometrial hyperplasia (based on severity of bleeding and patient BMI) are considered and discussed. The patient agrees to a diagnostic transvaginal ultrasound. This reveals an endometrial lining which is approximately 2.0 cm thick but no other uterine abnormalities. Visualization of the ovaries also reveals no abnormality. Results are discussed with the patient and consent is obtained for further evaluation via D&C endometrial biopsy (EMB). EMB pathology report notes the following: “Scant fragments of shedding weakly proliferative endometrium with secretory glands and extensive squamous morular proliferation.” Written commentary expands upon this statement noting, “Squamous morules can be seen in association with normal endometrium, endometrial polyp, atypical polypoid adenomyoma, endometrial hyperplasia, or a low-grade malignancy. Clinical correlation and/or D&C is advised if clinically indicated.”
After a discussion of the biopsy results and the risks and benefits of treatment options, including more-extensive D&C and hysterectomy, the patient desires a robotic hysterectomy for the definitive treatment of endometrial squamous morules and menometrorrhagia. In addition, the patient requests removal of her right ovary due to persistent right lower quadrant pain and for the prevention of future ovarian cysts. A robotic hysterectomy with bilateral salpingectomy and right oophorectomy is planned.
The patient undergoes general endotracheal anesthesia. A vaginal speculum is inserted, and four abdominal ports are placed and attached to the da VinciÒ robot. Abdominal inspection reveals dense adhesions spanning the omentum, greatly obscuring the pelvis. These adhesions are excised, permitting visualization of the pelvic cavity which contains a bulky, irregular uterus. Additional adhesions can be seen between portions of the bowel, omentum, and left ovary (Figure 1). These are lysed to facilitate salpingectomy. When observing the right adnexa, a large remnant of the patient’s previous ovarian cyst is noted along with ovarian adhesions to the right pelvic side wall (Figure 2). This ovary is removed as planned. Orienting inferiorly, dense adhesions are seen along the anterior surface of the bladder. These are excised down to the lower segment of the uterus and the uterus and fallopian tubes are subsequently extracted.
The patient leaves the operating room in stable condition and is admitted for postoperative monitoring and is then discharged without complications. Subsequent biopsy of the uterus reveals a benign endometrial polyp without hyperplasia or malignancy. The specimen weighs 193.6 g. Biopsies of the right ovary and bilateral fallopian tubes also reveal benign pathology. The patient is expected to make a full recovery in four to six weeks.
