A 27-year-old, nulliparous (0-0-0-0), married woman was referred to our institution with a huge pelvic mass and left flank pain. She had no history of surgical or medical disease. Transvaginal ultrasonography revealed a 16 cm right adnexal cyst with intramural nodules and thickened cyst wall (). Abdomino-pelvic computed tomography (CT) scan showed a 16 cm cystic mass with enhancing solid intramural nodules in the pelvic cavity (). The CT scan showed no evidence of ascites, peritoneal seeding, omental cake, or pelvic or para-aortic lymph node involvement. It looked like an epithelial ovarian cancer because the CT scan showed delayed enhancement. Her serum cancer antigen 125 (CA-125) concentration was 19.3 U/mL (reference value, <35 U/mL), and the results of other preoperative work-up tests were unremarkable.\nWe performed an exploratory laparotomy through a low midline abdominal incision, which revealed a 16 cm right paratubal cyst completely differentiated from the right ovary and fallopian tube. Paratubal cystectomy was performed without rupture of the cyst. Frozen section analysis of the specimen showed that it was a paratubal serous borderline tumor. Exploration of the entire peritoneal cavity showed no evidence of intraperitoneal tumor spread. Her fallopian tubes, ovaries and uterus were not involved. Washing cytology and multiple peritoneal biopsies were taken. Because the patient and her husband had a strong desire to preserve fertility, her uterus and both adnexae were preserved.\nGrossly, the tumor had a homogeneous, purplish white inner surface and multiple papillary projections up to 2.1 cm in greatest dimension (). The external surface of the tumor was homogeneously purplish white and smooth, with multifocal hemorrhage. However, there was no evidence of surface involvement. The final pathology results were identical to the frozen biopsy results indicating that the mass was a paratubal serous borderline tumor (). The results of the peritoneal washing cytology and multiple biopsies were negative.\nHer postoperative course was uneventful and she was discharged 5 days after surgery. Regular check-ups at the outpatient clinic include serum CA-125 measurements, transvaginal ultrasonography, and/or abdomino-pelvic CT. She delivered a healthy baby at term 13 months after surgery. Twenty months after surgery, she is doing well, without evidence of disease.
A 31-year-old woman presented with abdominal distention and discomfort worsening over the past 6 months. Concurrently, she had development overactive bladder symptoms, bloating, and dyspepsia. Her medical history was pertinent for epilepsy controlled with antiepileptic medications. Urine analysis was negative for any signs of infection, and her pregnancy test was negative. Abdominal examination was positive for a firm and distended abdomen, uniformly enlarged from the xiphoid bone to the pubic symphysis. No tenderness was reported on palpation; however, pressure was endorsed. A bedside abdominal ultrasound was performed that revealed an abdomen fully distended with fluid, initially suspected to be ascites. Computed tomography in 2.5 mm helical slices with both IV and oral contrast suggested the presence of an encapsulated cystic mass containing clear fluid (6 Hounsfield units). Dimensions reported were 36 cm in long axis, 28 cm in transverse diameter, and 15 cm in anteroposterior diameter, corresponding to 7 liters in volume, suggestive of a right ovarian cystadenoma (Figures and ). No capsular irregularities were seen or intracystic vegetations identified. Concurrently noted was right renal pelvicalyceal dilatation resulting from compression due to the proximity of the right ureter with the renal pelvis measuring 2 cm in anteroposterior diameter. No abdominal ascites or other abdominopelvic abnormalities noted. Tumor markers were in the normal ranges (CA125: 12.13 U/ml, CEA:1.51 ng/ml, and AFP: 1.46 IU/ml). While understanding her risks, the patient stressed the avoidance of excision of ovarian or fallopian tissue due to fertility concerns and preferred that the cyst be removed in a cosmetic manner including avoidance of larger laparotomy incisions.\nThe patient underwent resection of the mass. The procedure was begun by drainage of the cyst in order to identify the stalk and excise all cyst walls. A 3 cm supraumbilical incision was performed with careful dissection until reaching the peritoneal cavity. An Alexis O™ wound protector/retractor Applied Medical was introduced through the small incision permitting better visualization of the cyst (). Three hemostats were used to hold the cyst wall in place, followed by meticulous introduction of an 11 mm trocar into the cyst cavity under direct vision. This was followed by insertion of a 5 mm suction tube through the trocar to aspirate the fluid contents while avoiding spillage of fluid into the peritoneal cavity. Eight liters of serous fluid were aspirated. Following fluid evacuation, the cyst wall had collapsed. The trocar site in the cyst wall was sutured shut in a purse-string manner followed by a second closure layer. Then, the cyst was released off the hemostats, and the laparoscopic gel cap was fitted onto the Alexis retractor to convert the abdominal incision into a laparoscopic port site. This was used to insufflate the abdomen with CO2. Thereafter, 2 additional 5 mm trocars on each side of the midline were introduced.\nThe cyst borders were identified (). Using the bipolar forceps and scissors, it was completely dissected off the fallopian tube. Both the fallopian tube and ovarian tissues were noted to be intact. The cyst was removed through the supraumbilical incision and sent to pathology. The trocars were removed and all incisions approximated as per protocol. The patient was discharged soon thereafter from the observation unit.