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The website of the Royal College of Obstetricians and Gynecologists has plenty of useful features for students and to clinicians looking for guidelines on specific topics. There are about 75 Green Top Guidelines, Working Party Reports and Opinion papers giving detailed evidence based literature on topics in obstetrics and gynecology. They are downloadable at no cost.


This is the website of the Royal Australian and New Zealand College of Obstetricians and Gynecologists. It has a number of articles, statements and guidelines on a variety of OBGYN topics. The site features RANZCOG material as well as material from other bodies that have been endorsed by this College.


The International Society of Gynecological Endoscopists features videos, articles, journal links and newsletters. There are links to other endoscopy societies and organizations as well.


Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses' health study.

Obstet Gynecol. 2009 May;113(5):1027-37.

Parker WH, Broder MS, Chang E, Feskanich D, Farquhar C, Liu Z, Shoupe D, Berek JS, Hankinson S, Manson JE.

John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90401, USA. wparker@ucla.edu

OBJECTIVE: To report long-term health outcomes and mortality after oophorectomy or ovarian conservation.

METHODS: We conducted a prospective, observational study of 29,380 women participants of the Nurses' Health Study who had a hysterectomy for benign disease; 16,345 (55.6%) had hysterectomy with bilateral oophorectomy, and 13,035 (44.4%) had hysterectomy with ovarian conservation. We evaluated incident events or death due to coronary heart disease (CHD), stroke, breast cancer, ovarian cancer, lung cancer, colorectal cancer, total cancers, hip fracture, pulmonary embolus, and death from all causes.

RESULTS: Over 24 years of follow-up, for women with hysterectomy and bilateral oophorectomy compared with ovarian conservation, the multivariable hazard ratios (HRs) were 1.12 (95% confidence interval [CI] 1.03-1.21) for total mortality, 1.17 (95% CI 1.02-1.35) for fatal plus nonfatal CHD, and 1.14 (95% CI 0.98-1.33) for stroke. Although the risks of breast (HR 0.75, 95% CI 0.68-0.84), ovarian (HR 0.04, 95% CI 0.01-0.09, number needed to treat=220), and total cancers (HR 0.90, 95% CI 0.84-0.96) decreased after oophorectomy, lung cancer incidence (HR=1.26, 95% CI 1.02-1.56, number needed to harm=190), and total cancer mortality (HR=1.17, 95% CI 1.04-1.32) increased. For those never having used estrogen therapy, bilateral oophorectomy before age 50 years was associated with an increased risk of all-cause mortality, CHD, and stroke. With an approximate 35-year life span after surgery, one additional death would be expected for every nine oophorectomies performed.

CONCLUSION: Compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer. In no analysis or age group was oophorectomy associated with increased survival.

Surgical approach to hysterectomy for benign gynecological disease.

Cochrane Database Syst Rev. 2009 Jul 8;(3):CD003677.

Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW, Kluivers KB.

Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Johan de Wittlaan, Arnhem, Netherlands, 80 6828 WJ.

BACKGROUND: The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions depending on the part of the procedure performed laparoscopically.

OBJECTIVES: To assess the most beneficial and least harmful surgical approach to hysterectomy for women with benign gynaecological conditions.

SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (15 August 2008), CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), EMBASE (1980 to August 2008), Biological Abstracts (1969 to August 2008), the National Research Register, and relevant citation lists.

SELECTION CRITERIA: Only randomised controlled trials comparing one surgical approach to hysterectomy with another were included.

DATA COLLECTION AND ANALYSIS: Independent selection of trials and data extraction were employed following Cochrane guidelines.

MAIN RESULTS: There were 34 included studies with 4495 women. The benefits of VH versus AH were speedier return to normal activities (mean difference (MD) 9.5 days), fewer febrile episodes or unspecified infections (odds ratio (OR) 0.42), and shorter duration of hospital stay (MD 1.1 days). The benefits of LH versus AH were speedier return to normal activities (MD 13.6 days), lower intraoperative blood loss (MD 45 cc), a smaller drop in haemoglobin (MD 0.55 g/dl), shorter hospital stay (MD 2.0 days), and fewer wound or abdominal wall infections (OR 0.31) at the cost of more urinary tract (bladder or ureter) injuries (OR 2.41) and longer operation time (MD 20.3 minutes). The benefits of LAVH versus TLH were fewer febrile episodes or unspecified infection (OR 3.77) and shorter operation time (MD 25.3 minutes). There was no evidence of benefits of LH versus VH and the operation time (MD 39.3 minutes) as well as substantial bleeding (OR 2.76) were increased in LH. For some important outcomes, the analyses were underpowered to detect important differences or they were simply not reported in trials. Data were absent for many important long-term outcome measures.

AUTHORS' CONCLUSIONS: Because of equal or significantly better outcomes on all parameters, VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH however the length of the surgery increases as the extent of the surgery performed laparoscopically increases. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards.

Laparoscopic hysterectomy with and without a robot: Stanford experience.

JSLS. 2009 Apr-Jun;13(2):125-8.

Nezhat C, Lavie O, Lemyre M, Gemer O, Bhagan L, Nezhat C.

Center for Special Minimally Invasive Surgery, Stanford University Medical Center, Palo Alto, California 94304, USA. cnezhat@stanford.edu

OBJECTIVE: To compare robotic-assisted laparoscopic hysterectomy (RALH) with a matched control group of standard laparoscopic hysterectomy (LH).

METHODS: A retrospective chart review of all RALH was performed. All cases were compared with a matched control group of standard LH. Comparisons were based on Fisher's exact, Mann-Whitney, and exact chi-square tests.

RESULTS: Between January 2006 and August 2007, 26 consecutive RALH were performed (10 with bilateral salpingo-oophorectomy). These were compared with 50 matched control standard LH (22 with bilateral salpingo-oophorectomy). The 2 groups were matched by age (P=0.49), body mass index (P=0.25), gravidity (P=0.11), previous abdomino-pelvic surgery (P=0.37), and size of the excised uterus (P=0.72). Mean surgical time for RALH was 276 minutes (range, 150 to 440) compared with 206 minutes (range, 110 to 420) for standard LH (P=0.01). Blood loss, hospitalization length, and postoperative complications were not significantly different. No conversion to laparotomy was reported in either group.

CONCLUSION: Robotic technology was successfully used for hysterectomy with a similar surgical outcome to that of standard LH. This technology offers exciting potential applications, especially for remote telesurgery, and to facilitate teaching of endoscopic surgery.

Cystic Endometriosis in a Huge Degenerated Subserous Leiomyoma Mimicking Bilateral Multicystic Endometriomas in an Infertile Woman with Diminished Ovarian Reserve: A Rare Endometriotic Implantation

Case Rep Obstet Gynecol. 2016; 2016: 2713943; Published online 2016 Feb 29. doi: 10.1155/2016/2713943; PMCID: PMC4789423

Safak Hatirnaz, 1 , * Sabri Colak, 2 and Abdulkadir Reis 3

Introduction : Leiomyoma is the most common benign gynecological tumor seen in women Hyaline degeneration is the most common leiomyoma degeneration while cystic degeneration and calcific degeneration can be seen in leiomyomas Endometriosis is a common gynecologic disease affecting 10% to 15% of reproductive age women and is associated with various degrees of fertility problems .Endometriosis is defined as the presence of endometrial glands and stroma at extrauterine sites.It is a common, benign, chronic, estrogen-dependent disorder.

Case : 46-year-old woman with 8 years of primary infertility was admitted for bilateral multicystic complex adnexal masses diagnosed 4 years ago as bilateral endometriomas. She had 7 IVF attempts and only in 3 cycles; embryo could be transferred with no clinical outcomes. She had a history of laparoscopic endometrioma surgery 8 years ago and endometriomas on both ovaries were aspirated and their capsules were excised together with the laparoscopic excision of a subserous myoma. Ca 12-5 and Ca 19-9 values had been high before the laparoscopic surgery. She had no other medical or surgical history and all biochemical serological and hormonal parameters were normal other than high Ca 12-5 and Ca 19-9 which supported the diagnosis of endometrioma.

MRI investigation was carried out 2 years ago and bilateral endometriomas were reported without any radiological signs of malignancy. All attempts for fertility were failed due to either the absence or diminished ovarian response to ovarian hyperstimulation by gonadotropins. Some cycles were monitored naturally with no collected oocytes.. Oocyte retrieval (OR) by bypassing the endometriomas was not possible technically because the masses on both sides were huge and multilobulated and ovaries could not be discriminated easily. In two cycles the endometriomas were aspirated to reduce the size of the mass and to obtain oocytes easily under the suppressive antibiotherapy.

She decided to have the surgical operation and admitted for surgery at 31.03.2015. Pelvic MRI (Figure 1), Ca 12-5, Ca 19-9, and all preoperative tests were carried out same day and open surgery under general anesthesia was planned and carried out at 01 04 2015 by a Pfannenstiel incision. The mass could easily be seen from the abdominal wall before making the incision. A huge lobulated smooth surface mass of 22 × 18 × 10 cm in size was seen by opening the peritoneum and the first impression of the surgical team was malignancy and peritoneal washing was aspirated for cytological evaluation in Figures Figures222 and and55.

Figure 1
Figure 1 : MRI picture of the patient.

Figure 2
Figure 2 : Pedunculated huge mass originating the anterior surface of the uterus.

Figure 3
Figure 3 : Both tubas and ovaries seen (no endometrioma or endometriotic lesions).

Figure 4
Figure 4 : Blue discoloration-lesions on the mass.

Figure 5
Figure 5 : Extirpated leiomyomas.

The mass was well vascularised and adherent and a very thick vascularised adhesion was separated by electrocautery and sutured. Then the mass was taken out and it was a great surprise for all the team that the huge mass was originating from the anterior surface of the uterus just below the right corn and was evaluated as pedunculated degenerated leiomyoma with a thick pedicle.

Thorough search of the uterus and ovaries revealed 4 subserous leiomyomas of different sizes and both ovaries were free from any endometriotic lesions and left fallopian tube was adherent to the posterior of the uterus. Left ovary was found atrophic and right ovary was found smaller than normal. No endometriomas or endometriotic lesions were seen on the ovaries, tubes, and the uterus. Multiple leiomyomas at different size were seen on the surface of the uterus and uterus myomatosis was diagnosed intraoperatively.

She was supposed to have bilateral endometriomas for long time and the mass was misinterpreted as endometrioma both clinically and radiologically. The reason why the mass was interpreted as multilobulated bilateral endometrioma was due to the chocolate coloured aspiration materials seen in oocyte pick up procedures and also high Ca 12-5 and Ca 19-9 values. The mass was excised from the uterus by sharp dissection and the uterus was sutured with 1/0 Vicryl. Macroscopical evaluation of the mass at the operating theatre revealed multiple small nodules and a small leiomyoma seen on the surface close to the pedicle of the mass. Intraoperative evaluation showed multiple blue discolorations on the mass and no solid component was seen within the excised mass. The other leiomyomas were excised and sutured and the adherent left side tube was released from the uterus by sharp dissection and following hemostasis, irrigation, and aspiration, abdominal wall was closed layer by layer. Total amount of blood loss was 150 mL and the duration of operation was one and a half hours and no surgical and anesthesiological complications were observed. The pathology lab was informed verbally about the case and detailed information was given and aspirated fluid and the extirpated leiomyomas were sent to the pathology laboratory for cytological and pathological evaluation.

Intraoperative and postoperative macroscopic figures are shown in Figures Figures22–5.

3. Pathology Report

3.1. Cytological Diagnosis

No malignant cells were elucidated from the peritoneal aspiration fluid.

3.2. Macroscopy

A mass weighed 1285 grams and 18 × 18 × 8 cm in size with smooth surface was evaluated and 10 × 7 cm surgical excision site was visualised together with nodular leiomyomas (one separated from the mass and another in size of 4 cm). The mass was excised sagittally and first impression of the mass was cystic degenerated leiomyoma with mucoid melting plus multiloculated cystic mass (12 × 8 × 7 cm in size) filled with sticky dark brown liquefied bloody fluid (chocolate cyst) (Figure 6).

Figure 6
Figure 6 : Macroscopic figure; endometrioma in the pseudocystic degenerated mass.

3.3. Microscopy

Endometrial glandular epithelial linings were found in the wall of blood filled wide cystic structures in the dissections of degenerated leiomyoma and multiple foci of endometriosis and wide range of old blood (hemosiderophages) were found in the leiomyoma (Figures (Figures77 and and88).

Figure 7
Figure 7 : Endometriotic focus having endometrial stroma and glands in leiomyoma.

Figure 8
Figure 8 : Cystic endometrial epithelial lining in leiomyoma (HE ×200). Cystic endometriosis in degenerated leiomyoma (microscopic Figures Figures77 and and88).

3.4. Immune Histochemical Study (IHC)

Immunohistochemical tests including actin, CK7, CK20, oestrogen receptor, and progesterone receptor were studied (Figures (Figures99 and and1010).

Figure 9
Figure 9 : Actin immunoreactivity in neoplastic smooth muscle cells (IHC ×200).

Figure 10
Figure 10 : Nuclear progesterone receptor immunoreactivity in both smooth muscle cells and endometrial epithelial cells (IHC ×400).

3.5. Pathological Diagnosis

Cystic endometriosis in a huge degenerated leiomyoma originates from anterior uterine serosa.

Discussion : Uterine leiomyomas affect 20%–30% of women older than 35 years and exhibit various growth patterns and can be symptomatic as abnormal bleeding dysmenorrhea pelvic pain and pressure related symptoms to neighboring organs [2, 10]. Subserous leiomyomas are relatively asymptomatic until they become huge masses. Smooth muscle tumors can undergo secondary changes like hyaline, cystic, myxoid, and red degenerations depending on their location or size [11, 12] mostly due to improper blood supply of such hungry tumors.

Cystic degeneration may be a sequela of edema and reported to be seen in 4% of all leiomyomas [11, 12]. The wall and septum of the cystic leiomyomas are thick as in this case [2, 5, 11, 12]. A pedunculated leiomyoma can grow into the broad ligament and become parasitic and can detach from the uterus and be nourished by the retroperitoneal blood supply [5, 12].

Extrauterine leiomyomas are rare and these benign tumors originating from smooth muscle cells usually arise in the genitourinary tract (in the vulva, ovaries, urethra, and urinary bladder) but may arise in nearly any anatomic site. In addition, unusual growth patterns may be seen, including benign metastasizing leiomyoma, disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis, parasitic leiomyoma, and retroperitoneal growth. However, some extrauterine leiomyomas may mimic malignancies, and serious diagnostic errors may result. The most useful modalities for detecting extrauterine leiomyomas are ultrasonography, computed tomography, and magnetic resonance (MR) imaging. The superb contrast resolution and multiplanar capabilities of MR imaging make it particularly valuable for characterizing these tumors, which usually show low signal intensity similar to that of smooth muscle on T2-weighted images. The radiologist's recognition of this and other characteristic features may help steer the clinician toward timely, appropriate management and away from unnecessary, potentially harmful treatment [13].

Pedunculated cystic leiomyomas should be considered in the differential diagnosis of multiloculated cystic adnexal masses since sonographic and CT findings cannot differentiate these tumors from ovarian malignancy [11]. Typical appearances of uterine leiomyoma at magnetic resonance (MR) imaging are well established, and diagnosis is usually easy.

However, cases that are extremely difficult to differentiate from other conditions are occasionally encountered. To understand the wide spectrum of MR imaging findings, such unusual appearances can be classified into three categories: degeneration and other histopathologic findings, specific types of unusual leiomyomas, and unusual growth patterns. The common types of degeneration are hyaline (>60% of cases), cystic (approximately 4%), myxoid, and red. Edema is not a phenomenon of degeneration but is a common histopathologic finding (approximately 50% of cases). Hemorrhage, necrosis, and calcification (approximately 4% of cases) may also be observed. Specific types of unusual leiomyomas include lipoleiomyoma and myxoid leiomyoma, which may have MR imaging features characteristic enough to allow differentiation from other gynecologic and nongynecologic diseases. Intravenous leiomyomatosis, metastasizing leiomyoma, diffuse leiomyomatosis, and peritoneal disseminated leiomyomatosis represent unusual growth patterns; other unusual growth patterns are retroperitoneal growth, parasitic growth, and the pattern that may occur in cervical leiomyoma. Because leiomyomas are the most common gynecologic tumors and are exclusively benign, it is important to be familiar with the variety of MR imaging appearances of uterine leiomyomas to distinguish them from other significant diseases [14].

Endometrioma located mostly in the ovaries is a benign cystic tumor formed by the invagination of the cortex of the ovary. Invagination of the endometriotic lesions is the main phenomenon for the formation of endometriotic masses and this process is also seen in deep infiltrating endometriosis, especially in lower intestinal endometriosis lesions. Endometriotic lesions make the neighboring organs and tissues adhere to ovary to make conglomerated mass lesions as its nature.

The implantation of the endometriosis into the degenerated myoma may be due to the inoculation of endometriotic cells by follicular aspirations during OR but we cannot explain the myth of the absence of endometriotic implants on pelvic organs or any remnants of the bilateral endometriomas on both ovaries since the patient had a history of laparoscopic surgery for bilateral endometriomas together with laparoscopic subserous leiomyoma extirpation. The invagination of the endometriomas from the needle insertion sites into the degenerated myoma might be the reason but this could be a probable hypothesis not the fact because the capsule of the leiomyoma was very thick.

However the pedicle insertion site to the mass was very thin compared to the rest of the mass and one small leiomyoma and 3-4 soft nodules were seen at the insertion site. The biggest cystic endometriotic lesion was close to the edge of the capsule and that site was thin too.

In one of the rarest disease leiomyomatosis peritonealis disseminata (LPD) endometriosis can coexist in some lesions and this may be explained due to submesothelial multipotent stem cells also called secondary Müllerian system and endometrium originates from the same epithelium; thus endometriosis can coexist with disseminated leiomyoma [12].

Conclusion : Degenerated pedunculated leiomyomas can be misdiagnosed as adnexal masses both clinically and radiologically. Endometriosis can be seen in rare locations. Cystic endometriosis located in a huge pedunculated degenerated leiomyoma is an extremely rare endometriotic implantation and to the best of our knowledge this is the first case reported.


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