ovarian residual syndrome
Introduction
Introduction to ovarian residual syndrome Ovarian residual syndrome refers to a group of syndromes in which functional ovarian tissue reappears after vaginal or abdominal hysterectomy for bilateral ovaries and produces symptoms and signs such as pelvic pain or mass. In 1958, BrentanoPF and GroganRH described the syndrome successively. After surgery, pathological observation confirmed that the intrinsic patients had ovarian tissue in the site where there should be no ovarian tissue. basic knowledge The proportion of illness: 0.003% Susceptible people: women Mode of infection: non-infectious Complications: ovarian cancer
Cause
Ovarian residual syndrome etiology
(1) Causes of the disease
Ovarian residual syndrome occurs mostly in patients with a history of difficult pelvic surgery. If the pelvic vessels are more difficult to stop bleeding during the first operation, or because of pelvic tissue adhesion, the anatomical relationship is unclear and difficult to separate, or the tumor has changed normally. The structure, morphology and adjacent relationship between the tissues have caused difficulties in surgery and some ovarian tissues have not been completely removed. These remaining ovarian tissues and ovarian tissues in other parts of the pelvic cavity have no ovarian blood supply, but they can still be used. Experience necrosis, cystic changes and tumor-like changes, and even retain its function, combined with extensive pelvic adhesions, is the main cause of pain.
In pelvic endometriosis, pelvic inflammatory disease and tumor surgery, the ovaries can not be completely removed due to the following factors:
1. Local vascular hyperplasia, congestion, making it difficult to stop bleeding.
2. Adhesion changes the local anatomy, and separation is difficult.
3. Tumor compression is occupied, causing local anatomical changes.
4. When the pelvis funnel ligament is clamped during surgery, it is too close to the ovary, which may result in the ovary not being completely removed.
The ovarian tissue that remains on the pelvic peritoneum can obtain blood supply from the surrounding tissue, continue to have endocrine function, and adhere to the surrounding tissue to the follicular fluid containing various enzymes, forming a pelvic mass, causing a series of symptoms and signs. .
5. In modern times, ORS occurred after laparoscopic resection of the ovaries.
(two) pathogenesis
The theoretical basis of the ovarian residual syndrome was first proposed by Shenwell and Weed in 1970. They implanted the ovarian cortex in the abdominal cavity of four ovariectomized cats. After 4 months of implantation, two cats were observed to have estrus. After 9 months, the other 2 cats had ovarian cyst formation during the second laparotomy and saw follicular growth, which proved that the ovarian cortex survived after the blood supply was cut off, and continued to exert endocrine function.
Due to pelvic inflammation, tumor or endometriosis caused by pelvic soft tissue and vascular changes, the residual ovary can grow and function in other parts of the pelvic cavity, so it is also proposed to use "ovarian implant syndrome" (ovarian implant syndrome) word.
Prevention
Ovarian residual syndrome prevention
In order to prevent the occurrence of intrinsic, it is believed that the ovaries must be removed during hysterectomy, but most scholars believe that this syndrome is not common, and the problem of ovarian retention during hysterectomy should be determined by age.
Complication
Ovarian residual syndrome complications Complications ovarian cancer
Individual patients complicated with ovarian cancer and pelvic fibrous tissue adhesions.
Symptom
Symptoms of ovarian residual syndrome Common symptoms Lower abdominal pain Abdominal pain Sexual intercourse difficulty dull pain Menopausal blood pelvic mass Ovary deficiency or hypoplasia pelvic mass intestinal adhesion
Because ORS often occurs after difficult pelvic surgery, its clinical manifestations are more complicated, summarized as follows:
1. The most common clinical manifestation of ORS is lower abdominal pain with pelvic mass, which often occurs within a few weeks and years after difficult bilateral ovariectomy. It occurs in 5 years after surgery, and the lower abdomen pain accounts for about 65%. The mass is about 75%.
2. Pain manifestations are diverse, persistent or intermittent, periodic or persistent pain in one or both lower abdomen, dull pain, tingling or progressive abdominal pain, can be radiated to the perineum, partially radiated to the back, some cases The pain is very serious and requires an emergency.
3. There is a sense of pelvic pressure.
4. Most patients have sexual intercourse or difficulty in sexual intercourse.
5. A small number of rib pain can occur due to invasion of the fallopian tube and urinary tract infection often occurs. Functional ovarian residual tissue obstructs the bladder outlet, resulting in acute urinary retention. The residual ovary is prone to cystic changes, resulting in distal obstruction of the ureter. Intravenous pyelography can be seen ureteral dilatation or displacement, urinary tract obstruction is characterized by periodic episodes, manifested as renal colic, hematuria, bladder irritation and so on.
Examine
Examination of ovarian residual syndrome
Hormone level testing, tumor marker examination.
1. Intravenous pyelography can have pyelectasis and ureteral displacement.
2. B-ultrasound can be seen in the mass and surrounded by a small amount of liquid.
3. CT examination can not only locate and determine the size of the tumor, but also help the diagnosis of patients with clinical symptoms without touching the tumor.
4. Laparoscopy.
5. Histopathological examination.
Diagnosis
Diagnosis and differentiation of ovarian residual syndrome
Diagnostic criteria
The clinical diagnosis of ovarian residual syndrome is difficult. The literature reports that the number of patients undergoing this syndrome is as many as 7 to 8 times. Therefore, ovarian residues should be considered in patients with pelvic pain after bilateral oophorectomy. The possibility of syndromes, especially those with high risk factors.
1. Preoperative diagnosis of ovarian residual syndrome depends mainly on medical history. Patients often have a history of bilateral ovariectomy such as endometriosis or pelvic inflammatory disease. Surgery is generally difficult or has multiple surgical history, and chronic Recurrent pelvic pain, a few with peritoneal symptoms, persistent or periodic lower abdominal pain and dyspareunia, with pelvic mass, individual patients may have rib pain.
2. In addition to medical history, it is also necessary to refer to physical examination and gynecological examination, hormone level detection and ultrasound, CT examination, etc., pelvic mass in the double diagnosis due to dense adhesion of the pelvic cavity is often difficult to detect, and the diagnosis rate of triple diagnosis Higher, often thickened iliac crest, small nodules or pelvic mass at the main ligament, B-ultrasound mass is helpful for diagnosis and pelvic exploration preoperative positioning, B-ultrasound image is a clear boundary pelvic cavity The lumps echo and there is a small amount of fluid around them.
3. ORS diagnostic criteria
(1) Resection of bilateral ovaries in one or more gynecologic operations.
(2) In the absence of estrogen and progesterone replacement therapy, serum FSH was pre-menopausal (<40 mU/ml), indicating the presence of functional ovarian tissue. After successful ovarian residual tissue resection, FSH levels were 1 week after surgery. More than 100mU/ml inside.
(3) During reoperation, it was found that laparoscopic exploration showed dense pelvic adhesions, small nodules on the pelvic floor, pelvic funnel ligament and ureter, or pelvic masses of 3 to 10 cm in size, located near the iliac vessels, or vagina At the side of the stump, it adheres to the surrounding tissues such as the bladder, rectum, and sigmoid colon. The mass can also surround the ureter. The tissue removed during the operation is confirmed to be ovarian tissue.
4. Pathological diagnosis Most of the resected ovarian remnant tissue sections showed normal ovarian tissue, simple cysts, cystic follicles or follicular cysts, hemorrhagic corpus luteum or multiple corpus luteum with varying degrees of degeneration in the lumps or adherent thickened tissues. Yellow outside the luteinized granulosa cells and follicular endometrial cells, confirmed that the residual tissue is functional ovarian tissue, Symmonds et al reported that the residue can be cystic adenoma, ovarian portal cell residual and ovarian endometriosis cyst, Burke et al. (1997) has reported a case of ovarian residual syndrome, which occurs in ovarian mucinous carcinoids after 1 year of total uterus and double-attachment resection. The clinical diagnosis is tumor recurrence, aspiration biopsy is malignant, and immunocytochemistry is neuroendocrine. Source, surgical resection shows that the tumor is ovarian tissue, with corpus luteum and follicular cysts, so the histology of ovarian residual syndrome can show benign ovarian follicular cyst with cell atypical, Narayansingh et al (2000) reported in ovarian residues Among patients with syndromes, there are those with ovarian cancer.
5. Intravenous pyelography can show renal pelvic dilatation and ureteral displacement.
6. GnRHa stimulation test, the triggering of gonadotropin release, stimulated a significant increase in estradiol value to confirm the diagnosis of ORS, the method is as follows: Leuprolide (Leuprolide), continuous medication, can produce initial stimulation, followed by continuous inhibition The role of gonadotropin-releasing hormone secretion keeps the residual ovarian tissue at rest, no follicular development and ovulation, and accompanying changes in ovarian volume. Leucyl valine can cause complete ovarian suppression. The diagnosis of pelvic cystic mass was performed after the removal of the lateral accessory.
Clomiphene eliminates the negative feedback inhibition of estradiol by competing for the estrogen receptor in the hypothalamic region, and promotes the secretion of gonadotropin from the pituitary gland. The patient can stimulate the residual ovarian tissue and make the follicular hyperplasia cystic. Structure, easy to identify by ultrasound.
7. CT and MRI In the literature reports on CT and MRI for ORS diagnosis, the diagnostic value is still inconclusive.
Differential diagnosis
It should be differentiated from para-ovary or excess ovary: the para-ovary is too much ovarian tissue in the vicinity of the normal ovary, it can be connected with the ovary or develop into the ovary; the extra ovary is clearly separated from the ovary in the normal position, is started by another independent The follicular ovarian tissue that develops from the base is usually located in the inferior pole of the kidney. In addition, it should be distinguished from residual ovarian syndrome (ROS). ROS refers to the purpose of retaining the ovary during hysterectomy, but the postoperative ovary occurs. Pathological changes, and ORS is a syndrome of a series of clinical signs and symptoms that appear after ovariectomy.
