Late aortic lymphocele and residual ovary syndrome after gynecological surgery
World Journal of Surgical Oncology
Late aortic lymphocele and residual ovary syndrome after gynecological surgery
Maria Pastore 1
Natalina Manci 1
Claudia Marchetti 1
Francesca Esposito 1
Marialetizia Iuliano 1
Lucia Manganaro 0
Pierluigi Benedetti Panici 1
0 Dept of Radiology, "La Sapienza" University , Rome , Italy
1 Dept of Obstetrics and Gynecology, "La Sapienza" University , Rome , Italy
Background: Gynecological surgery, as radical hysterectomy or pelvic and aortic lymphadenectomy, accounts for more than 50% of iatrogenic injuries. In premenopausal women, an hysterectomy with ovarian sparing and concomitant lateral ovarian transposition is frequently performed. However, the fate of the retained ovary is complicated by the residual ovarian syndrome (ROS) and one of the most common postoperative complications of the lymphadenectomy procedure is the lymphocele, with an average incidence of 22-48.5%. The differential diagnosis of a postoperative fluid collection includes, in addition to a lymphocele, urinoma, hematoma, seroma or abscess and the computed tomography (CT) findings alone is not enough. Case presentation: We describe a patient, affected by ROS concomitant with a asymptomatic lymphocele, initially confused with an aortic lymph nodes relapse, after abdominal radical hysterectomy. The patient was subjected to a surgical approach, included a diagnostic open laparoscopy and laparotomy with sovraombelico-pubic incision, wide opening of the pelvic peritoneum and retroperitoneum. Examination of the mass revealed, macroscopically, a ovary with multiloculated cystic masses filled with clear or yellow serous fluid and the layers were composed by flat or cuboidal mesothelial cells. Conclusion: The tribute of this case illustrates the atypical appearance with uncertain aetiology after complex imaging. Gynecologist and radiologist should acquaint with the appearance of fluid collection (urinoma, lymphocele, seroma, hematoma, abscess) in gynecologic oncology follow-up to properly differentiated from tumor recurrence.
Gynecological surgery, as radical hysterectomy or pelvic
and aortic lymphadenectomy, accounts for more than
50% of iatrogenic injuries [1,2], such as urinoma,
lymphocele, haematoma, seroma or abscess [3-5].
Furthermore, women of reproductive age having an hysterectomy
because of benign or malignant disease require the
gynecologist to decide whether to preserve or to remove the
gonads. Beyond the age of 40 and especially over 45 years,
many surgeons perform the removal of the ovaries. On
converse, the preservation of one or both ovaries at the
time of hysterectomy (retained ovary) consents to
preserve the important role in steroid metabolism even after
the menopause, but the residual ovary syndrome (ROS)
results in the 23% of women [6-8].
We describe a case of ROS concomitant with a pregress
asymptomatic lymphocele, in a 37-year-old woman who
developed an abdominopelvic mass, initially confused
with a recurrence in the aortic lymph nodes, 12 years after
abdominal radical hysterectomy for cervical cancer.
A 37-year-old woman was admitted to our Institute with
suspected an abdominopelvic mass, without univocal
interpretation, considering the peculiarity of the onset
and of the radiological appearance.
Twelve years earlier, the patient was treated with radical
abdominal hysterectomy. Whertheim-Meigs radical
hysterectomy, systematic pelvic and aortic lymphadenectomy
with conservation and lateral transposition of the right
ovary for stage IB1 cervical cancer. One of 47 pelvic lymph
nodes removed was positive. Adjuvant external
radiotherapy was administered for a total of 4500 cGy. At the end
of treatment, the patient developed asymptomatic aortic
lymphocele, measuring 4 cm in diameter and it was
untreated. The follow-up was negative until December
2006 when the patient exhibited dyspareunia, lower
abdominal and back pain. The first examinations carried
out, ultrasonography and computed tomography (CT)
showed an irregular loculated cystic mass measuring 8 7
cm, located in aortic area. The serum level of CA125 was
found increased to 89 U/mL and there was a slow and
These symptoms worsened and the first diagnosis was
confirmed by subsequent several imaging studies. In
March 2007, the patient underwent to further abdominal
and pelvic CT scan that explained a pelvic mass with
complex features; pelvic MRI confirmed a cystic pelvic mass of
18 8 cm size but with a solid component (figure 1).
About the radiological appearance of a complex cystic
mass, strongly evocative for a tumor recurrence, the
oncological radiologist equip dissuaded from any diagnostic
approaches, such as fine-niddle aspiration, sclerotherapy,
catheter drainage. For all these reasons, the patient was
subjected to a surgical approach, included a diagnostic
open laparoscopy and laparotomy with
sovraombelicopubic incision, wide opening of the pelvic peritoneum
and retroperitoneum. Because of adhesions and distorted
anatomy, the dislocated ureters were at risk during surgery
and a retrograde dissection was necessary. Frozen section
examination of the mass revealed, macroscopically, a
ovary with multiloculated cystic masses filled with clear or
yellow serous fluid and the layers were composed by flat
or cuboidal mesothelial cells. It was observed a
lymphocele adherent to it (figure 2, figure 3). The patient
made an uneventful recovery and was discharged 4 days
later. After surgery, symptoms disappeared and she was
well at her two weeks postoperative check-up and up to
Lymphadenectomy plays an important role in the
management of gynecological malignancies for the assessment
of lymph node status. In premenopausal women, an
hysterectomy with ovarian sparing and concomitant lateral
ovarian transposition is frequently performed.
However, the fate of the retained ovary could be
complicated by the residual ovarian syndrome (ROS): it consists
of recurrent or chronic pelvic pain (7177%), disturbance
of the urinary tract (33%), dyspareunia (67%), pelvic
mass on bimanual examination (1425%), as a single or
a cluster of symptoms. The interval between hysterectomy
and the appearance of symptoms surgery for the residual
adnexal disease syndrome range from 4 months to 26
years. Over 50% of the women presented within 5 years,
and 75% within 10 years. It is estimated that at least
2.85% of patients will develop ROS and require surgery
for it following hysterectomy [9,10]. In literature, it is also
described an increased incidence of functional ovarian
cysts and peritoneal inclusion cysts, partially accounting
the above mentioned symptoms.
All at once, one of the most common postoperative
complications of the lymphadenectomy procedure is the
lymphocele, with an average incidence of 2248.5% .
Usually, it became detectable within 38 weeks after
surgery and the symptomatology depends by the size, the
locations and the possible sovrainfection. The differential
diagnosis of a postoperative fluid collection includes, in
addition to the lymphocele, urinoma, hematoma, seroma
or abscess . About abdominal hematoma and abscess
the diagnosis seems easier. The urinoma is an
encapsulated collection of urine that forms from urine leakage
and its radiological appearance is of a soft tissue mass
mistaken with lymphocele. Urinary symptoms, percutaneous
fluid chemistries analysis or delayed CT scanning
demoncFCyiogsrtuiocrnerael1tTro2p-wereiitgohnteadl immaasgse shows multiloculated nature of
Coronal T2-weighted image shows multiloculated nature of
cystic retroperitoneal mass. Surgical pathology confirmed
multicistic ovarian tissue with lymphocele adherent to it.
strating ureteral extravasation is crucial to differentiate
urinomas rather than lymphoceles.
In this case, the presence of a small, asymptomatic
lymphocele was diagnosed 6 weeks after surgical procedure by
SFuigrguircael 2specimen of right ovary
Surgical specimen of right ovary. Ovarian pedicle adherent to
aortic lymphocele are both visible.
FmMiiugmluticrfokeliln3icgonlaordoalvaroiratnictirsescuuerirnesnidce retroperitoneal mass
Multifollicolar ovarian tissue inside retroperitoneal mass
mimicking nodal aortic recurrence.
CT scan. Considering that most of the small lymphocysts
regress spontaneously, a conservative approach was
opted. Remarkably, in this report the lymphocyst
preserved the same aspects, either for the size and the
location, until 12 years later, when a CT showed irregular
cystic pelvic mass, mimicking malignant recurrent
ovarian/lymphonodal lesion. Although late relapse for
cervical cancer after the fifth years is very rare, estimated about
047.5%, one third of it had lymph node metastasis and
the CT scan is helpful for early diagnosis . This
hypothesis was also corroborated by the increase of the
tumor marker CA 125. The patient was finally subjected to
surgery because, according with Kim et al. ,
lymphoceles occurring later than 1 year should be subjected to a
more thorough diagnostic investigation in order to
exclude a recurrent disease. In our experience there have
been no previously documented cases in which such final
diagnosis was registered.
This case emphasizes that the gynecologist and radiologist
should acquaint with the appearance of transposed
ovaries and their abnormalities, to properly differentiated
from other possible entities, such as peritoneal
metastases, urinomas, seroma, hematoma, abscess, cystic
neoplasm; the report also strongly supports the evidence that
more close radiological examinations in this setting of
patients are required in order to promptly exclude tumor
MP Conceived of the study. Carried out the design of the
study, participated in the sequence alignment and drafted
the manuscript. NM Participated in the study's design and
coordination. Gave final approval of the version to be
published. CM. Carried out the analysis and
interpretation of data. Helped to draft the manuscript. FE
Participated in the study's design and coordination. Performed
the statistical analysis. MI Helped to draft the manuscript.
Participated in the design. LM Carried out the acquisition
of data. Participated in the design. PBP Gave final
approval of the version to be published and revised the
All authors read and approved the manuscript.
Written informed consent was obtained from the patient for publication of
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