Author Informaion
Durga Valvi*, Rashmi
Prasad**, Parulekar SV***, Samant PY****
(* Assistant Professor,
** Second Year Resident, *** Professor and Head of Department, ****Additional
Professor. Department of Obstetrics and Gynecology, Seth
G.S. Medical
College and KEM
Hospital , Mumbai India
Abstract
Posthysterectomy vault
calcifications are seen because of current diseases, or
congenital alterations, inflammatory illness and tumors, even in para-physiologic
conditions. These are commonly seen in women who undergo
hysterectomy without salpingo-oophorectomy or who have history of pelvic inflammatory diseases. We present a
case of vault prolapse with computerized tomography (CT) scan showing vault of
3 cm in diameter with calcified specks within it. On laparoscopy there was
signs of tuberculosis.
Introduction
The female pelvis is an
anatomic region which contains urogenital system, part of gastrointestinal
tract, important blood vessels, lymphatic, nerves, and part of musculoskeletal
system. All these structures might house or
generate pelvic masses. There
are several gynecological causes responsible for calcified pelvic mass. These
include a calcified neoplasm of ovary or fallopian tube, tubo-ovarian abscess,
pelvic inflammatory diseases (especially tuberculosis), hydrosalpinx, ectopic
pregnancy, calcifications in uterine mass (especially leiomyoma), phlebolith, a
lithopedion a foreign body, and secondary metastasis.[1, 2] It has also to be considered that
nongynecological causes like bladder stone or tumor, ureteral stones, pelvic kidney, peritoneal carcinomatosis,
lymphadenopathy, musculoskeletal tumors could be responsible for pelvic mass.[4,5
] Hysterectomy without
salpingo-oophorectomy is most frequently done procedure for benign causes among
45-50 years age group. Adnexae are commonly responsible for calcified pelvic
masses after hysterectomy.
Case report
A 54 years old patient presented with post hysterectomy
vault prolapse. Hysterectomy was done 3 years ago for abnormal uterine
bleeding. Her had had a full term outlet forceps delivery. She was diagnosed to have abdominal
tuberculosis on diagnostic hystero-laparoscopy 2 years ago, which was treated
over 8 months. Her general and systemic examination revealed no abnormality.
Her abdomen was soft, nontender. A speculum examination showed a third degree
vault prolapse, grade 1 cystocele, grade 1 rectocle and lax perineum. On per
vaginal examination approximately 3 cm diameter, nontender mass was felt at the
apex of the vault. Her CA 125 was 7u/ml. Ultrasonography of the pelvis showed
post hysterectomy status. CT Scan showed
vault to be 3 cm in diameter, with calcified specks at the vault. The patient
underwent diagnostic laparoscopy which showed retort shaped left fallopian tube
engulfing the left ovary (tubo-ovarian mass), calcified plaque near the right
cornu, and normal right fallopian tube and ovary. Since it was a quiescent tubo-ovarian mass that had been treated medically, it was left undisturbed.
Figure 1. CT Scan of the pelvis showing calcification the vaginal vault.
Discussion
Accurate diagnosis is important for management of a post
hysterectomy calcified pelvic mass. There are several
gynecological causes responsible for calcified pelvic mass. These include a
calcified neoplasm of ovary or fallopian tube, tubo-ovarian abscess, pelvic
inflammatory diseases (especially tuberculosis), hydrosalpinx, ectopic
pregnancy, calcifications in uterine mass (especially leiomyoma), phlebolith, a
lithopedion a foreign body, and secondary metastasis.[1, 2] It has also to be considered that
nongynecological causes like bladder stone or tumor, ureteral stones, pelvic
kidney, peritoneal carcinomatosis, lymphadenopathy, musculoskeletal tumors
could be responsible for pelvic mass.[3,4] History, detailed clinical examination, tumor markers and
imaging are useful for accurate diagnosis. CT scan and magnetic resonance
imaging are useful in detecting and staging of gynecological malignancies and
in detecting the origin of extra-gynecological pelvic masses.[5] All the differential diagnosis has to be
thought of and a definitive diagnosis should be made before resorting to any
operative intervention. Diagnostic laparoscopy followed by biopsy of suspected
lesion can be done and the material
obtained can send for histopathological, cytological examination, and culture
if there is any suspicious of pelvic inflammatory disease. In our case there
was a dilemma about the management of the patient. The exact nature of the mass
was not known, though pelvic tuberculosis was suspected. The prolapse required
a vaginal repair. However the mass had to be removed abdominally, if it
warranted removal. A laparoscopy was performed to make a diagnosis and remove
the mass laparoscopically or by laparotomy, to be followed by vaginal repair of
the prolapse. Laparoscopy showed signs of old healed tuberculosis and hence the
tubo-ovarian mass was not removed. Vault repair with anterior colporrhaphy and
posterior colpoperineorrhaphy was done after the laparoscopy.
References
- Sheng Hsiang Lin,MD; Hsiao Li Lo, RN ; A Calcified Tumour in the Pelvis. Annals of the Academy of Medicine, Singapore 2011;40(12) 546-7.
- Koehler F, Kivelitz D. A Calcified Pelvic Mass N Engl J Med 2004;350:e21.
- Alessandrino F, Dellafiore C, Eshja E, Alfano F, Ricci G, Cassani C, La Fianza A. Differential Diagnosis for Female Pelvic Masses. In Okechukwu Felix Erondu. editor. Medical Imaging in Clinical Practice. First ed. InTech. 2013. Available from: http://www.intechopen.com/books/medical-imaging-in-clinical-practice/differential-diagnosis-for-female-pelvic-masses.
- Burgener, Kormano, Pudas, Differential Diagnosis in Conventional Radiology. 2007. Georg Thieme Verlag KG; pp 642-648. Available from: https://www.thieme.de/medias/sys_master/8804797382686/9783136561034_musterseite_642_647.pdf?mime=application%2Fpdf&realname=9783136561034_musterseite_642_647.pdf
- Johnson RS. Radiology in the management of the ovarian cancer. Clin Radiol 1993; 48:75-82.
Citation
Valvi D, Rashmi Prasad R, Parulekar SV, Samant PY. Post hysterectomy vault calcification – Therapeutic dilemma. JPGO 2014 Volume 1 Number 8 Available from: http://www.jpgo.org/2014/08/post-hysterectomy-vault-calcification.html