مدیریت وارونگی غیر مامایی رحم با استفاده از رویکرد ترکیبی واژینال و لاپروسکوپی Management of nonpuerperal uterine inversion using a combined laparoscopic and vaginal approach

CASE REPORT A 40-year-old woman, who had previously delivered 4 infants vaginally and who had undergone 3 hysteroscopic resections of benign submucous leiomyomas, responsible for vaginal bleeding during the last year, presented with lower abdominal pain, radiating to the vagina. The pain had become increasingly aggravated during the preceding week. A protruding mass of approximately 7 cm was found on speculum examination, with minimal bleeding and inability to visualize the cervix. The size of the uterus was difficult to appreciate by bimanual abdominopelvic examination because of the distended abdomen and abdominal pain. Transvaginal ultrasonography revealed a uterus measuring 60
۹۲ mm, with an endometrium 8 mm thick and a cervicoisthmic mass of 70 mm, suggesting the diagnosis of a prolapsing submucous pedunculated myoma. As this hypothesis was considered accurate, neither magnetic resonance imaging (MRI) nor computed tomography were performed. Following the patient’s request for definitive treatment, a total laparoscopic hysterectomy was planned. Laparoscopic exploration showed complete invagination of the uterus through the vagina (Figure 1), confirming the diagnosis of a stage 2 uterine inversion. After ligation of the uterine arteries at their origin, the round, broad, and uterosacral ligaments and the fallopian tubes were coagulated and sectioned (Video). The procedure was then completed using a vaginal approach; circular colpotomy was performed following the line separating the normal-colored vaginal wall and the ischemic tissue, which had undergone marked color change after uterine artery ligation (Figure 2). The uterus was then retrieved, and vaginal closure was performed using interrupted resorbable sutures. The patient was discharged at postoperative day 3 and showed favorable outcomes. Pathologic examination confirmed uterine inversion resulting from a 7 cm myoma attached to the uterine fundus (Figure 3). Although the majority of the endometrium was removed by prolonged abrasion, small persistent fields of cylindric mucosecretory glandular epithelium free of carcinoma cells remained. COMMENT Uterine inversion in a nonpregnant woman is a rare occurrence, with only 150 cases reported from 1887 to 2006, and the large majority occurring in women over 45 years old.1 In 85% of the cases these were due to benign uterine pathologies, whereas in 15% of cases they were related to malignant tumors. Uterine sarcomas (leiomyosarcoma, rhabdomyosarcoma,sarcoma of the endometrial stroma) were more frequently reported than endometrial carcinoma or mixed müllerian tumors.2Uterine inversion has previously been reported in only 5 women under 45 years of age, of whom 3 presented with rhabdomyosarcomas, 1 with endometrial carcinoma, and only 1 with a benign submucous myoma.3 Pathophysiology of uterine inversion appears to be multifactorial, including thinness of the uterine wall, rapid tumor growth, the enlarged size of the tumor located either at or adjacent to the uterine fundus, a small tumor pedicle, and distention of the uterine cavity leading to cervical dilatation. The main clinical symptoms are abnormal vaginal bleeding; lower abdominal pain or vaginal pressure; and in rare cases, acute urinary retention by urethral compression. Clinical diagnosis of uterine inversion might be made difficult where the cervix is hidden behind the tumor and the uterine fundus cannot be palpated;