Author
information
Asmita
Patil*, Parulekar SV**, Gwendolyn Fernandes***
(*Senior
Resident, **Professor and head of the department, Department of Obstetrics and
Gynecology; *** Associate Professor, Department of Pathology, Seth GS Medical
College and KEM Hospital ,
Mumbai , India
Abstract
Prolapse of the fimbria
of the fallopian tube is a rare complication of hysterectomy. It can be
confused for simple conditions like vault granulations and serious conditions
like recurrent cancer in the vaginal vault. Owing to its rarity, it is being
omitted from modern textbooks of gynecology. We present a case of
posthysterectomy fimbrial prolapse to bring about awareness of its existence
once more.
Introduction
The incidence is less than 1% of all hysterectomies, and much
lower in better centers. Though it is a benign condition, failure to diagnose
it in time and treat it appropriately may prove quite harmful to the patient.
The condition was over diagnosed in the past, and most of the cases turned out
to be vault granulations. As a result, the condition is being omitted from the
modern textbooks of gynecology. Future generations of doctors may not even
learn of it until they actually encounter a case, treat it as a case of vault granulations
and have catastrophic results. We present this case to bring about awareness of
its existence once more.
Case Report
A 45 year old woman
presented at our tertiary level care center with a complaint of left iliac
fossa pain for a period of one month. The pain was dull and dragging. She had
had three normal vaginal deliveries in the past, and had undergone a total
abdominal hysterectomies one year ago for abnormal uterine bleeding. Details of
the operation including histopathology report of the specimen were not
available, except that the recovery after the operation had been uneventful.
There was no history of fever, low
backache, leucorrhea, postcoital bleeding or dyspareunia in the last one
year. Her vital parameters were within normal limits. General and systemic
examination revealed no abnormality. A speculum examination showed a 3x2x1 mm
pink fleshy mass near the left angle of the vault of the vagina. There was no
space between the lesion and surrounding vagina. This lesion did not bleed to
touch during the process of obtaining of a Pap smear. Bimanual pelvic
examination revealed no pelvic mass. In order to distinguish between a vault
granulation, fimbrial prolapse, and a primary or recurrent malignant lesion
(after an abdominal hysterectomy, which could have been done for a uterine
malignancy), traction test was performed. The lesion was gently held with
sponge holding forceps and gentle traction was done on it. It reproduced the
pain that she had been experiencing in the last one month. So a diagnosis of
fimbrial prolapse was made. An excision biopsy of the lesion followed by
reposition of the tubal stump into the peritoneal cavity and repair of the
opening in the pelvic peritoneum and vaginal vault was planned. Unfortunately
the lesion came off when held with a sponge holding forceps. No opening could
be found in the vault from where the residual fallopian tube could be dissected
out. There was no active bleeding from the vault. Considering that the vault
had been closed by fibrosis around the prolapsed fimbria, it was decided to
observe the woman for development of any symptoms. She remained well. Her
pelvic pain disappeared too.
Histopathological
examination showed a fallopian tubal structure with typical histology. The
tubal mucosa was composed of glands lined by pseudo stratified ciliated
epithelium. Prominent cilia were seen. Lamina propria and bundles of smooth
muscle fibers of the fallopian tube were seen surrounding the glandular
epithelium. Dense mixed inflammatory infiltrate composed of lymphocytes, plasma
cells, few neutrophils and histiocytes were seen. Many proliferating
capillaries were also seen. No nuclear atypia or malignant changes were seen in
the glandular epithelium and mucosa. The presence of prominent cilia and few
bundles of smooth muscle fibers of the fallopian tube clinched the diagnosis of
prolapsed fallopian tube into the vaginal vault.
Figure 1.
Microphotograph showing fallopian tubal mucosa with underlying lamina propria
and few bundles of smooth muscle. (H&E x100).
Figure 2.
Microphotograph showing dense inflammatory infiltrate surrounding the glands. A
few perforating capillaries are also seen. (H&E x100).
Figure 3.
Microphotograph showing glands lined by ciliated columnar epithelium. The
inflammatory infiltrate is composed of lymphocytes, plasma cells, and
neutrophils. (H&E x400).
Figure 4. Oil immersion
photography to highlight the cilia. (H&E x1000).
Discussion
Prolapse of the fimbria
of the fallopian tube is a rare complication of hysterectomy. The incidence is
said to be 0.5% with vaginal hysterectomy, 0.06% with abdominal hysterectomy,
and 0 with laparoscopic hysterectomies.[1] Another series of 8444
hysterectomies showed an incidence of 0.2%, being equal after vaginal and
abdominal hysterectomies.[2] Pozzi reported this condition for the
first time in 1920.[3] All subsequent reports are of a few cases
each, because of the rarity of the condition. Risk factors for development of
this condition include low socio-economic status, postoperative formation of hematoma
and/or infection of the vault, and an open vaginal cuff.[2] The case reported by us is the first in 32
years in our experience, and that too where the primary operation had been done
at another center. The low incidence might reflect meticulous closure of the
pelvic peritoneum and the vagina separately, prevention of formation of a vault
hematoma by achieving hemostasis prior to the closure and low incidence of
vault sepsis. Another reason for the low incidence could be the practice of not
fixing the vault to the cornual pedicles, which keeps the tubes away from the
vault. The reason for adopting this practice was that the cornual structures
could not support the vault anyway, and fixing the ovaries so close to the
vault would possibly lead to collision dyspareunia. Low incidence of fimbrial
prolapse could be a coincidental benefit of this practice. The mean time
interval between the hysterectomy and development of fimbrial prolapse is about
four months, and the longest reported interval is 32 years.[4] This
suggests that the patient has a peritoneovaginal fistula after the operation,
and chronic increase in the intraabdominal pressure results in extrusion of the
tubal fimbriae through the fistula. The patients present with pelvic pain,
vaginal spotting, leucorrhea and dyspareunia, though they may be asymptomatic
too. The diagnosis can be made by traction test, in which the lesion is held
with sponge holding forceps and gentle traction is made on it.[5] If
it is prolapsed fimbria of the tube, the traction gets transmitted to the
fallopian tube above the vault and causes the same pain that the patient has
been experiencing due to the fimbrial prolapse. If it is vault granulation or a
primary/recurrent cancer, the held portions gets detached easily and
painlessly. This tissue can be examined histologically and its nature
determined. Pap smear of the vault shows small ciliated columnar cells with
prominent nucleoli. Since presence of columnar cells is very rare in the vault,
a wrong diagnosis of a malignancy may be made.[6] Histology shows
intact fimbrial structures covered with columnar epithelium. It is often
misdiagnosed as adenocarcinoma because of the glandular architecture and
associated inflammatory atypia. However, a history of prior hysterectomy,
location of the lesion in the apex of the vagina, superficial ulcerated lesion
with an appearance of granulation tissues are important to note for making the
diagnosis.[7] Histopathology leads to a definitive diagnosis. The
presence of cilia, architecture of the fallopian tube and few bundles of smooth
muscle fibers help to clinch the diagnosis of prolapsed fallopian tube. Another helpful feature that aids the
diagnosis is the presence of dense inflammatory infiltrate in the lamina
propria surrounding the glands. Awareness of this lesion and careful
histopathological examination is important to avoid misdiagnosis of
adenocarcinoma of vaginal vault. Prolapsed fallopian tube needs to be mainly
differentiated from adenocarcinomas, primary and metastatic, endometriosis,
cysts of the mesonephric and paramesonephric ducts and vaginal adenosis.[8]
However their appearance is distinct and they should not be confused for a
fimbrial prolapse. A ureterovaginal or vesicovaginal fistula also cannot be
mistaken for a fimbrial prolapse because of the associated leak of urine.
Immunohistochemistry using pankeratin antibodies is useful in identification of
fimbria when in doubt.[9] A fimbrial prolapse is managed by making
an incision in the vault all around it, delivering a part of the tube into the
vagina, and excising it. The ligated stump of the tube is then reposited into
the pelvic cavity carefully and the opening in the pelvic peritoneum and the
vault of vagina is closed carefully to prevent a recurrence of the prolapse of
the tube or development of pelvic peritonitis by spread of bacteria from the
vagina to the peritoneal cavity.[10,11,12] Electrocauterizing the
prolapsed fimbria thinking it to be granulation tissue may prove catastrophic,
as the current may spread to the pelvic portion of the tube and to bowel if it
lies in close proximity to the tube.
References
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Pozzi M. Hernie de
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R Soc Obstet Gynecol Paediat Paris 1902 ;4:255-257.
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Citation
Patil A, Parulekar SV, Fernandes G.
Posthysterectomy Fimbrial Prolapse. JPGO 2014 Volume 1 Number 10.
Available from: http://www.jpgo.org/2014/10/posthysterectomy-fimbrial-prolapse.html