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What Do These MRI Findings Of Pelvic Cavity Indicate?
Question: Hi, please find the below details of a case with the attached relevant documents for your kind review and expert opinion
Chief complaints/reason for admission:
This is 36-year-old female member, who presented to the hospital with complaint of severe pelvis pain associated.
History of present illness:
• The member has been followed up in OB/GYN clinic of Al XXXXXXX Hospital for last 6-8 months.
• She has a history of recurrent visit with OB/GYN for the last 2 years with complaint of pelvic pain, which has been getting worse for the last 1 year.
• This has not responded to any oral medication.
• She also complains of heavy prolonged menstruation lasting 10 days associated with passing of clots.
• She has been diagnosed with uterine fibroids, which have started affecting her normal life activities and social life activities and prompting her to visit emergency departments frequently.
• She is nullipara (married for less than 1 year).
MRI of pelvic cavity:
• Bulky globular anteverted anteflexed uterus measuring about 7.9 x 7.8 x 9.3 cm in maximum height, side to side and longitudinal dimensions respectively.
• It harbors few well defined soft tissue mass lesions seen scattered in the uterine corpus.
• They assume interstitial locations with compression of the endometrial lumen.
• Multiple Fibroids. The larges one is seen located in the anterior uterine wall measuring about 4.9 x 5.8 x 3.5 cm in maximum AP, side to side and cranio-caudal dimensions respectively.
• It displays mixed iso and hypo-intense signal in T1W1 and deep hypointensity in T2W1 as compared to the adjacent myometrium.
• A well-defined cyst is seen in the right side of the pelvis related to the right ovary. It measures about 3.5 x 4.4 x 3.8 cm in maximum side to side, AP and height respectively. It displays high signal intensity in T1 W1 and intermediate to low signal in T2 and STIR W1 suggestive of blood products contents.
Impression:
• Bulky uterus harboring few interstitial leiomyomata.
• Right adnexal cyst, possibly endometrioma.
Past medical/surgical history:
Her past medical history is also positive for anemia, for which she is under treatment.
Diagnosis:
Multiple uterine fibroids.
The patient was scheduled for laparoscopic myomectomy for multiple fibroids but on the surgery the treating doctor sis not proceed with the myomectomy. he instead went for adhesiolysis only because of complete frozen pelvis (as per the attached notes) and risk of bleeding
Please provide us with the reply on the following questions
Kindly confirm the possibility of leaving the fibroids unremoved in this case; is it as per the best practice guidelines not to remove the fibroid in this case?
What complications can occur in this condition?
What should the patient follow up for after that and will she be needing the surgery afterwards?
Is there any possibility of fraud with not removing the fibroid?
Is frozen pelvis an indication for not performing myomectomy although its multiple?
many thanks for your assistance
Chief complaints/reason for admission:
This is 36-year-old female member, who presented to the hospital with complaint of severe pelvis pain associated.
History of present illness:
• The member has been followed up in OB/GYN clinic of Al XXXXXXX Hospital for last 6-8 months.
• She has a history of recurrent visit with OB/GYN for the last 2 years with complaint of pelvic pain, which has been getting worse for the last 1 year.
• This has not responded to any oral medication.
• She also complains of heavy prolonged menstruation lasting 10 days associated with passing of clots.
• She has been diagnosed with uterine fibroids, which have started affecting her normal life activities and social life activities and prompting her to visit emergency departments frequently.
• She is nullipara (married for less than 1 year).
MRI of pelvic cavity:
• Bulky globular anteverted anteflexed uterus measuring about 7.9 x 7.8 x 9.3 cm in maximum height, side to side and longitudinal dimensions respectively.
• It harbors few well defined soft tissue mass lesions seen scattered in the uterine corpus.
• They assume interstitial locations with compression of the endometrial lumen.
• Multiple Fibroids. The larges one is seen located in the anterior uterine wall measuring about 4.9 x 5.8 x 3.5 cm in maximum AP, side to side and cranio-caudal dimensions respectively.
• It displays mixed iso and hypo-intense signal in T1W1 and deep hypointensity in T2W1 as compared to the adjacent myometrium.
• A well-defined cyst is seen in the right side of the pelvis related to the right ovary. It measures about 3.5 x 4.4 x 3.8 cm in maximum side to side, AP and height respectively. It displays high signal intensity in T1 W1 and intermediate to low signal in T2 and STIR W1 suggestive of blood products contents.
Impression:
• Bulky uterus harboring few interstitial leiomyomata.
• Right adnexal cyst, possibly endometrioma.
Past medical/surgical history:
Her past medical history is also positive for anemia, for which she is under treatment.
Diagnosis:
Multiple uterine fibroids.
The patient was scheduled for laparoscopic myomectomy for multiple fibroids but on the surgery the treating doctor sis not proceed with the myomectomy. he instead went for adhesiolysis only because of complete frozen pelvis (as per the attached notes) and risk of bleeding
Please provide us with the reply on the following questions
Kindly confirm the possibility of leaving the fibroids unremoved in this case; is it as per the best practice guidelines not to remove the fibroid in this case?
What complications can occur in this condition?
What should the patient follow up for after that and will she be needing the surgery afterwards?
Is there any possibility of fraud with not removing the fibroid?
Is frozen pelvis an indication for not performing myomectomy although its multiple?
many thanks for your assistance
Brief Answer:
Fibroids can be removed by open surgery instead of laparoscopy
Detailed Answer:
Hello,
Thanks for your query.
I have read you query and I understand your concerns about fibroids.
Following is my reply:
1) Fibroids should have been removed ideally. Since fibroids could not be removed due to frozen pelvis, she needs to go ahead with another team of of surgeons comprising of gynecologist and surgeon in case of bowel injury. Proper counseling about possibility of bowel injury to be explained to patient. Leaving behind fibroids will not help her much.
2) Bowel and bladder injury are possible during surgery. If not operated, she will continue to suffer the problems she suffered all these years. She might even suffer from infertility as her uterus is studded with fibroids.
3) Surgery will be needed on a later date if not performed now.
4) This cannot be called fraud as surgeon clearly states frozen pelvis.
5) Frozen pelvis is an indication where myomectomy could not be performed by laparoscopy. But open method could have been tried to remove fibroids in this case if not possible by laparoscopy. But again that depends upon operating surgeon.
Let me know if you need anymore clarification.
Fibroids can be removed by open surgery instead of laparoscopy
Detailed Answer:
Hello,
Thanks for your query.
I have read you query and I understand your concerns about fibroids.
Following is my reply:
1) Fibroids should have been removed ideally. Since fibroids could not be removed due to frozen pelvis, she needs to go ahead with another team of of surgeons comprising of gynecologist and surgeon in case of bowel injury. Proper counseling about possibility of bowel injury to be explained to patient. Leaving behind fibroids will not help her much.
2) Bowel and bladder injury are possible during surgery. If not operated, she will continue to suffer the problems she suffered all these years. She might even suffer from infertility as her uterus is studded with fibroids.
3) Surgery will be needed on a later date if not performed now.
4) This cannot be called fraud as surgeon clearly states frozen pelvis.
5) Frozen pelvis is an indication where myomectomy could not be performed by laparoscopy. But open method could have been tried to remove fibroids in this case if not possible by laparoscopy. But again that depends upon operating surgeon.
Let me know if you need anymore clarification.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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