Introduction
Iatrogenic endometriosis (IE) is the presence of endometrial glands and stroma out of the uterus following certain surgical interventions, such as total or supracervical hysterectomy, myomectomy, and cesarean section [
1]. The most common localizations for IE are cesarean scares (skin scare, uterus scare), trocar sites, sigmoid colon, ovaries, bladder, vaginal vault, and the parietal peritoneum [
2,
3]. Pain, dyspareunia, bleeding, and palpable mass are the common symptoms of IE. The interval between previous surgery and occurrence of symptoms ranges between first menstruation time and 7 years after surgery [
4]. IE is reported with a rate of 1.4% after hysterectomy [
5]. Data on IE is spare and comes from case reports and small case series. All these publications report series of gynecologic surgery cases due to benign diseases such as adenomyosis, uterine leiomyomas, and fibroids [
1,
5]. Supracervical hysterectomy is also a frequently used surgical treatment for apical pelvic organ prolapse (POP), which is followed by sacrocervicopexy [
6]. However, there are no data on IE after apical prolapse surgery in the current literature. Herein, we present a case report of a patient diagnosed with
de novo endometriosis 1 year after laparoscopic supracervical hysterectomy and sacrocervicopexy (LASH). To the best of our knowledge, this is the first such case report in the literature.
Discussion
Endometriosis has been known since its first description by Sampson in 1924 as the presence of functional endometrial tissues out of the uterine cavity [
7]. However, IE has been a subject of publications since the 1990s, after the popularization of laparoscopic and robotic total or supracervical hysterectomy procedures [
2,
8].
The rate of IE was reported to be 1.4% in a case-control study by Schuster
et al. [
5]. Among 464 hysterectomy cases, the data of 16 patients who were reoperated due to pain and bleeding were evaluated, and five cases with IE were identified. In a review published by Pereira
et al., 32 different publications were evaluated, and among 66 patients who underwent reoperation after hysterectomy, 4 with IE were identified [
1]. In these two publications, indications of hysterectomies were benign uterine diseases, whereas no data are currently available about IE after prolapse surgery. According to our clinical records, we have only 1 case of IE but 15 reoperations after 600 LASH procedures. It seems that our IE rate is lower than in the studies mentioned before. The underlying reason for this uncertain rate
of IE may be the limited number of cases in which reoperation is needed following total/subtotal hysterectomy, myomectomy, and LASH.
Hilger
et al. suggested that in the presence of endometriosis and adenomyosis at the time of previous surgery, retrograde flow from resting endometrial tissues in the cervix is a reason for IE after supracervical hysterectomy [
9]. Stefanović
et al. emphasized direct endometrial tissue implantation and seeding on pathogenesis of IE, especially after cesarean section surgery and the morcellation of uteri [
10]. We viewed our patient’s LASH surgery video record, and we did not see endometrial foci on the sacral promontory. Therefore, a missed endometrial lesion was not a possibility in our patient. Retrograde flow might also not be a reason for IE in our patient, owing to the closure of the peritoneum on the cervical stump. However, an early breakdown of sutures placed on the peritoneum above the cervix or laceration of the peritoneum might cause leakage from the cervix to the peritoneum, resulting in IE. The probable reasons for IE in our patient might be the seeding of endometrial cells secondary to morcellation and undiagnosed adenomyosis at the time of previous surgery.
Steiner
et al. first described electric morcellation of the uterus for laparoscopic hysterectomy in 1993 [
11]. Although it allows removal of the specimen without an incision, a lot of morcellator-related complications have been published in the literature. Milad
et al. reported morcellator-related injuries in 55 cases and deaths in 6 cases [
12]. Tulandi
et al. described pathogenesis of parasitic leiomyomas and disseminated peritoneal leiomyomas secondary to morcellation [
2]. Pereira
et al. described cancer tissue spreading to the peritoneal cavity in a case with occult malignancy in the uterus after use of a morcellator [
1]. In 2014, the U.S. Food and Drug Administration released a notification discouraging the use of electric morcellators [
13]. After this notification, Solima
et al. suggested using a confined morcellator with a specimen bag. They stated that leakage from the bag and increase in operation time were problems [
14].
In our practice, we routinely check patients in terms of uterine malignancies and use nonconfined morcellation preoperatively. We did not experience any injury or death related to morcellator use, and also no occult uterine malignancies were detected. However, after our present patient’s case, we can argue that unless the specimen bag is damaged, confined morcellation with a bag can be a beneficial option to avoid IE. Also removing the specimen via an incision to avoid IE can be discussed with the patient preoperatively.
Kill
et al. suggested that the most common symptoms of endometriosis are pain, dyspareunia, local mass effects, and bleeding [
4]. In our patient’s case, pelvic pain was the main symptom, and pain during deep vaginal palpation was the main finding on physical examination. Bazot
et al. stated that USG and MRI are the first-line diagnostic tools for endometriosis [
15]. However, they remarked on the limitations of MRI as absence of international consensus on reporting IE and the sensitivity of MRI for lesions > 7 mm. The limitation of US is that the success rate of detecting IE is operator-dependent [
15]. We determined hypervascularization and scare/fibrosis as findings of endometriosis on the basis of US. However, the localization of IE in our patient was the sacral promontory, and we thought these findings were secondary to mesh used during the previous LASH surgery.
In a review by Kızılay
et al., it was suggested that the treatment of endometriosis aims at pain relief, preserving fertility, and preventing obstruction [
7]. Oral contraceptive drugs, analgesic drugs, gonadotropin-releasing hormone agonists, and aromatase inhibitors are the first-line medical treatment options [
3]. Surgical excision is usually necessary to preserve fertility and to treat urinary obstruction related to endometriosis [
7]. When it comes to IE, there is no specific treatment algorithm in the literature; however, surgical excision has been discussed as the first treatment option by authors [
3‐
5]. In accordance with the literature, diagnostic laparoscopy and excision of endometriosis was our preferred treatment modality.
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