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Post Hysterectomy Vault Calcification – Therapeutic dilemma

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. Vault suspension with anterior colporrhaphy and posterior colpoperineorrhaphy was done. 


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
  1. 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.
  2. Koehler F, Kivelitz D. A Calcified Pelvic Mass N Engl J Med 2004;350:e21.
  3. 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.
  4. 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
  5. 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