evidence does not indicate that a superior method occurs among approaches involving laparoscopy, laparotomy, or different electrosurgical system as far as rates of live birth, clinical pregnancy, or miscarriage are concerned.

Regardless of whether laparoscopy is performed with or without robotic assistance, large myomas can be removed from the abdomen by introducing a power morcellator through a 10or 15-mm port. Using the morcellator, large myomas are cut into small pieces in the abdomen to facilitate removal and the risk of seeding macro or microscopic broid fragments is decreased. Despite the low risk of unexpected leiomyosarcoma, from 1 in 770 to 1 in 10,000 myoma specimens [12], the FDA issued a warning contraindicating the use of power morcellation for the removal of uterine tissue containing myoma [12].

Therefore, many surgeons have reverted to the original abdominal approach despite the known higher risk of morbidity. Alternately, some surgeons elected to perform lapa- roscopic-assisted ultra-mini-laparotomy. The technique involves performing all or most of the myomectomy laparoscopically. Prior to removing the specimen from the abdomen, a 3–5 cm Pfannenstiel incision is made, and the specimens are delivered through the mini-laparotomy. This can be done either directly or by placing the myoma in an endoscopic bag. Depending on the location and extent of the incision, the uterine incision can then be closed laparoscopically or through the same mini-incision. With this technique, patients still have the bene t of lower complication rates as well as a faster recovery and are usually discharged home within a day. Most recently, the FDA allows power morcellation only with the use of a tissue containment system (Pneumoliner), allowing some surgeons who have access to the system to resume performing laparoscopic and robotic myomectomies.

Patients with submucosal myomas should rst be offered a hysteroscopic approach, even in the presence of a larger sized myoma. With appropriate counseling and expertise, the submucous resection (SMR) can be performed safely with a rapid recovery. In addition, the time interval required before attempting conception is typically shorter after hysteroscopic SMR when compared to the abdominal approach, even when the SMR is performed over multiple sessions as described in the illustrated case here. Following any SMR, it is recommended that the cavity is re-evaluated, either with a midcycle ultrasound to con rm the presence of homogenous trilaminar endometrial stripe or with a saline infusion sonogram.

References

1.\ Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188(1):100–7.

2.\ Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R. Epidemiology of uterine broids: a systematic review. BJOG. 2017;124(10):1501–12.

3.\ Munro MG, Critchley HO, Broder MS, Fraser I, FIGO Working Group on Menstrual Disorders. FIGO classi cation system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113(1):3–13.

Chapter 17

Ovarian Cysts

Hey-Joo Kang

Case

A 31-year-old G0 presented to the ER with acute right lower abdominal pain. She reported a 2-month history of vague right lower quadrant fullness. The pain increased with physical exertion, but usually abated spontaneously. For the past 2 months, she was able to continue her daily functions as an art curator, exercise 2–3 times per week, and had a normal appetite. Menses were regular and monthly, with a normal ow, and her annual gynecologic exams and pap smears have been normal. She had been on oral contraceptive pills for the past 8 years and discontinued them 6 months ago when she and her husband decided to start trying to conceive.

Over the course of the past 1–2 days, the pain became more frequent and intense. She described the pain to be sharp and intermittent, with the nausea and vomiting occurring in the moments the pain was most intense.Attributing the symptoms to a take-out dinner she ate the night before, she decided to go to bed early and wait the customary 24 h for her symptoms to resolve. In the morning the pain became worse. On her way to the emergency room, she had diffculty walking, requiring to stop frequently until her husband hailed a taxi to take them to the door of the emergency room.

Vitals signs showed a temperature of 98.7, heart rate of 128 bpm, and BP of 140/70. Physical examination showed she was in acute distress and diaphoretic. Examination of her abdomen revealed guarding but no rebound. Her urine pregnancy test was negative. Her pelvic exam was notable for a right adnexal fullness and she was very uncomfortable on a bimanual exam. Her white blood cell count was mildly elevated, but her hemoglobin count and chemistries were normal. A pelvic sonogram and CT scan were ordered. The pelvic sonogram

H.-J. Kang (*)

Reproductive Medicine and Ob/Gyn, The Ronald Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Medical College of Cornell University, New York, NY, USA e-mail: hek9004@med.cornell.edu

P. H. Chung, Z. Rosenwaks (eds.), Problem-Focused Reproductive Endocrinology and Infertility, Contemporary Endocrinology, https://doi.org/10.1007/978-3-031-19443-6_17

The frst responsibility of the clinician is to assess if the cyst is likely benign or malignant, although admittedly there is no absolute way to know without tissue pathology. Pelvic ultrasound uses gray scale to determine solid versus uid and is highly effective at guiding the initial management of an ovarian cyst. Gray scale is a technique in which the ultrasound wave is depicted as a pixelated shade of gray; the darker the image, the longer the re ected wave took to return to the crystal. As such, uid-flled structures appear black and solid structures appear light gray to give the sonographer a two-dimensional view of the anatomy [1]. Doppler evaluation uses the change in frequency that results from sound waves re ecting off moving particles, providing information about arterial and venous blood ow to certain areas of interest. Features of a simple cyst are a small size (<3 cm), a round/oval shape, uniformly dark (anechoic), thin walls, and absence of internal ow with color doppler imaging. Based on the 2019 Society of Radiologists consensus after review of 570 asymptomatic ovarian cysts [2], in premenopausal women, simple cysts up to 3 cm are considered normal. Simple cysts >3 cm but <5 cm should be described but do not require follow-up imaging, and >5 cm should have follow-up imaging to determine any change in size or spontaneous resolution.

Mature cystic teratomas (dermoid) are composed of differentiated elements from all three cell layers (ectodermal, mesodermal, and endodermal) and compose 95% of all ovarian teratomas. Dermoid cysts form by the failure of meiosis II or from a premeiotic cell in which meiosis I has failed [3]. They are almost always benign, but in 0.2–2% of cases, the components of a mature cystic teratoma can undergo malignant degeneration—the most common being squamous cell carcinoma arising from the ectoderm [4]. Risk factors for malignancy in a dermoid cyst is age over 45, tumor greater than 10 cm, rapid growth, and increased doppler ow to the internal part of the cyst [5].

Most women with dermoid cysts are asymptomatic despite growth to large (>5 cm) sizes, and the cysts are usually found incidentally on exam or ultrasound. Ovarian torsion is seen with a fair degree of frequency due to the weight of the cyst contents; however, rupture of the thick-walled cyst is uncommon. Case series of expectant management of dermoid cysts estimated the incidence of torsion at 3.5–11% [6]. Chemical peritonitis can result from the rare event of a rupture, leading to the formation of pelvic adhesions. The latter can be minimized by aggressive irrigation during surgery to remove the contents of the cyst spilled into the peritoneal cavity. Diagnosis of dermoid cysts by ultrasound shows a characteristic appearance with a heterogenous internal structure and a bright focus within the cyst with a reported specifcity of 98–100% [7]. Treatment is pre-emptive ovarian cystectomy to allow for a tissue diagnosis while avoiding an emergency surgical intervention for torsion or rupture, versus expectant management. For women who have completed childbearing, unilateral oophorectomy is also a reasonable option. Dermoid cysts are bilateral in 10–20% of cases but rarely recur within the same ovary after cystectomy.

The prevalence of endometriosis in reproductive aged women is 5–10% and, when present, can lead to ovarian endometriomas formed by active endometrial tissue within the ovary [8]. It is estrogen dependent for growth. If symptomatic,