Accepted Manuscript Giant Paratubal Cyst in Adolescence: Case Report, Modified Minimal Access Surgical Technique and Literature Review Elliot A. Asare , MD, Sarah Greenberg , MD, Sara Szabo , MD, PhD, Thomas T. Sato , MD PII:
S1083-3188(14)00375-1
DOI:
10.1016/j.jpag.2014.11.002
Reference:
PEDADO 1798
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 3 September 2014 Revised Date:
27 October 2014
Accepted Date: 13 November 2014
Please cite this article as: Asare EA, Greenberg S, Szabo S, Sato TT, Giant Paratubal Cyst in Adolescence: Case Report, Modified Minimal Access Surgical Technique and Literature Review, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.11.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Giant Paratubal Cyst in Adolescence: Case Report, Modified Minimal Access Surgical Technique and Literature Review Elliot A. Asare MD1, Sarah Greenberg MD1, Sara Szabo MD, PhD2, Thomas T. Sato MD3 1
RI PT
Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
2
Department of Pathology, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
3
AC C
EP
TE D
M AN U
SC
Department of Surgery, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
*Correspondence: Elliot Asare, MD Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave Milwaukee, WI 53226 o: 414-805-8632 m: 804-922-9267 E-mail: [email protected] 1
ACCEPTED MANUSCRIPT
ABSTRACT Background: Giant paratubal cysts are rare lesions that can present management
RI PT
challenges due to their enormous size. We present a modified minimally invasive approach for effective surgical management of giant paratubal cysts.
Case: A 19 year old female with worsening abdominal distension and metrorrhagia was
SC
diagnosed with a giant paratubal cyst. A modified, minimally invasive technique
designed to limit spillage of cyst fluid was successfully used for surgical management.
M AN U
Summary and Conclusion: 5500ml of cyst fluid was evacuated without spillage and near-complete excision of cyst was performed with preservation of adnexa. Preservation of the adnexa in adolescent females is critical and where minimally
AC C
EP
TE D
invasive approaches are possible, they should be employed.
2
ACCEPTED MANUSCRIPT
INTRODUCTION Giant paratubal or paraovarian cysts are rare lesions typically recognized during
RI PT
exploration following a clinical diagnosis of a suspected mesenteric or ovarian cyst. We present an adolescent female with a 5-kg paratubal cyst and describe the diagnosis, a modified minimal access surgical approach, pathology, and review of the literature.
SC
CASE
M AN U
Presentation
A 19-year-old G0P0 female presented with gradual abdominal distension over a period of eleven months, which she initially attributed to weight gain during her first year in college. Her abdominal distention was associated with metrorrhagia and progressive early satiety. She denied weight loss, fever, chills, night sweats, urinary tract
TE D
symptoms, or other gastrointestinal complaints. She was on no medications and there was no family history of ovarian neoplasms or polycystic ovarian disease.
EP
Clinical examination revealed a well-appearing, 74.5 kg, Tanner stage V female with notable non-tender protuberance of her abdomen and pelvis. Serum beta-HCG and
AC C
alpha-fetoprotein were normal. Abdominal and pelvic ultrasound demonstrated a 22.5 cm x 10.5 cm cystic abdominal mass, normal uterus, and bilateral ovaries. Subsequent CT scan image was obtained to delineate the origin of the cyst. This confirmed a homogeneous, unilocular, thin-walled cyst measuring 27cm x 23cm x 10cm (Figure 1). The cyst filled her pelvis and most of her abdominal cavity to the level of her liver with associated right hydronephrosis. There were no solid adnexal masses or pelvic lymphadenopathy. 3
ACCEPTED MANUSCRIPT
Surgical management Operative exploration was performed via a 6 cm suprapubic transverse incision. Clear
RI PT
pelvic fluid was aspirated and sent for cytology. To prevent spillage of cyst fluid into the peritoneal cavity, the end of a sterile ultrasound probe cover was fixed to the anterior cyst wall using 2-octyl cyanoacrylate (DermabondTM), and a percutaneous diagnostic peritoneal lavage catheter was inserted through the probe cover into the cyst using
SC
Seldinger technique; this was connected to suction. Approximately 5500 ml of clear,
M AN U
serous fluid was removed. The cyst had no attachments to the abdominal wall, intestine, or mesentery, and the decompressed cyst wall and attached structures were eviscerated. The uterus, right ovary and fallopian tube were normal. The cyst was densely fixed to an extremely elongated left fallopian tube and normal adjacent ovary. Near complete cyst excision was performed, and cyst wall remnants adherent to the
uneventful.
EP
Pathology
TE D
ovary and fallopian tube were left in situ to preserve these structures. Her recovery was
Microscopically, the well-developed paratubal cyst wall was lined with Mullerian
AC C
epithelium with underlying loose connective tissue stroma; there was a uniform dense collagenous wall (Figure 2). The cyst wall had a variable thickness fibrovascular layer intimately associated with smooth muscle bundles. There was no evidence of malignancy, borderline epithelium, vascular malformation, or other neoplasm. No ovarian stroma was found in any of the sections. Peritoneal fluid and cyst fluid cytology were negative for malignant cells.
4
ACCEPTED MANUSCRIPT
SUMMARY AND CONCLUSION Paraovarian or paratubal cysts arise from embryologic remnants located in the proximity
RI PT
of the broad ligament between the ovary and the fallopian tube .1 Variations in histopathology include mesonephric (Wolffian), mesothelial and paramesonephric
(Mullerian) origins.2 In a review of 79 females with paratubal cysts by Samaha and Woodruff, paramesonephric (Mullerian) histology was the most commonly encountered
SC
variant.2 Anatomic structures of Mullerian origin are the proximal two-thirds of the
M AN U
vagina, the uterus, cervix and fallopian tube.3 The secretory epithelium that lines Mullerian-derived structures accounts for the cystic dilatation of paramesonephric (Mullerian) cysts.2 Paramesonephric (Mullerian) cysts are responsive to hormonal stimulation, hence their observed incidence in post-pubertal females.2 The derivatives of
unlikely to form cysts.2,3
TE D
the mesonephric duct have muscular layers and minimal secretory activity hence
Incidence rates of paraovarian cysts are reported to be 17% to 33% for patients
EP
diagnosed with benign adnexal cysts .4 Paraovarian cysts are much more frequently encountered in women during the third and fourth decades of life compared to children
AC C
and adolescents. The incidence rate of neoplasm among reported cases of paraovarian cyst is 2-3% and includes cystadenocarcinoma, papillary carcinoma, and serous papillary neoplasms.5 Ovarian serous carcinoma accounts for 75-80% of ovarian epithelial carcinomas.7 The histologic appearance of ovarian serous tumors is similar to the glandular epithelial lining of the fallopian tube, leading to the proposition that serous epithelial carcinomas may arise from the distal fallopian tube.7 This proposition is of
5
ACCEPTED MANUSCRIPT
interest given the common embryologic origin of both the fallopian tube and paratubal cysts.
RI PT
Symptomatic complications of paraovarian cysts include hemorrhage, perforation, and torsion. Torsion may involve only the cyst itself, or the cyst and adjacent structures including the fallopian tube, broad ligament, or ovary. The risk of torsion appears
greater once cyst diameter exceeds 5 cm. Giant paraovarian cysts larger than 10 cm in
SC
diameter are extraordinarily unusual and anecdotal in the literature.8, 9,10 In 1964,
M AN U
Burnhill described the surgical management of a giant paraovarian cyst in a 38-year-old woman that required initial aspiration of 26 liters of fluid from the cyst prior to resection.10
Transpelvic or transvaginal ultrasound and axial imaging aid diagnosis and operative
TE D
planning; however, definitive diagnosis may require exploration to confirm cyst origin. The differential diagnosis of homogeneous, unilocular cysts during adolescence that fill the entire peritoneal cavity includes ovarian cyst, paraovarian cyst, mesenteric cyst, and
EP
abdominal or pelvic lymphangioma. Generally, these may be readily differentiated on imaging studies from more complex, muliticystic lesions caused by mucinous
AC C
carcinomatosis, peritoneal inclusion cyst, pancreatic pseudocyst, or echinococcal cystic disease. We utilized controlled cyst aspiration designed to avoid spillage and potential risk of peritoneal seeding in the extremely rare event of malignant neoplasm. Additionally, this approach allows for delivery of the cyst wall and adjacent structures through a single, limited incision. Pelosi and Pelosi were first to describe a technique in which through an anterior abdominal wall minilaparotomy, a surgical adhesive was used to attach a plastic wound dressing to the giant cyst wall and the cyst was drained with 6
ACCEPTED MANUSCRIPT
care to avoid intraabdominal spillage prior to resection.11 A similar minimal access approach was described by Rhode et al in which a large bore needle was used to decompress cyst through a 2-octyl cyanoacrylate (DermabondTM) dressing followed by
RI PT
cystectomy.12 Other minimally invasive techniques that involve cyst decompression prior to resection have subsequently been described.13, 14 Our approach builds on these
previously described techniques but our use of a sterile ultrasound probe cover as a
SC
conduit through which aspiration was done drastically reduced any chance of
M AN U
intraabdominal spillage.
Giant parovarian or paratubal cysts during adolescence are exceedingly rare and definitive preoperative diagnosis is challenging. Factors including patient symptoms, cyst size, appearance on imaging, and suspicion for malignancy may help guide surgical management. A single, limited incision technique with deliberate, protected
with these giant cysts.
EP
REFERENCES:
TE D
cyst aspiration prior to extracorporeal examination and excision is particularly useful
AC C
1. Barloon TJ, Brown BP, Abu-Yousef MM, Warnock NG. Paraovarian and paratubal cyst: preoperative diagnosis using transabdominal and transvaginal sonography. J Clin Ultrasound 1996;24: 117-122 2. Samaha M, Woodruff JD. Paratubal cysts: Frequency, histogenesis, and associated clinical features. Obstet Gynecol 1985;65:691-694 3. Oldham KT, Colombani PM, Foglia RP, Skinner MA. Principles and Practice of Pediatric Surgery. Second Edition. Lippincott Williams & Wilkins. 2005. p1606, p1622. 4. Okada T, Yoshida H, Matsunaga T, Koucihi K, Ohtsuka Y, Takano H, Horie H, Ohnuma N. Paraovarian cyst with torsion in children. J Pediatr Surg 2002;37:937-940
7
ACCEPTED MANUSCRIPT
5. Honore LH, O’Hara KE. Serous papillary neoplasms arising in paramesonephric parovarian cysts. A report of eight cases. Acta Obstet Gynecol Scand 1980;59(6): 525-8
RI PT
6. Berek JS, Hacker NF. Berek and Hacker’s Gynecologic Oncology. Fifth Edition. Lippincott Williams & Wilkins. 2010. P443-444. 7. Kostov M, Mijovic Z, Mihailovic D. Giant parovarian cyst in a child complicated with torsion. Vojnosanit Pregl 2008;65(11):843-6 8. Letourneur B, Grandjean S, Richard P, Parant O. Management of a giant parovarian cyst. Gynecol Obstet Fertil 2006;34(3):239-41
SC
9. Cevrioglu AS, Polat C, Fenkci V, Yilmazer M, Yilmaz S, Dilek ON. Laparoscopic management following ultrasound-guided drainage in a patient with giant paraovarian cyst. Surg Endosc 2004;18:346
M AN U
10. Burnhill MS. Giant parovarian cyst: Report of a case. Obstet Gynecol 1965;26:275-6 11. Pelosi MA II, Pelosi MA III. A novel minilaparotomy approach for large ovarian cysts. OBG Management. February 2004: 17-30 12. Rhode JM, Advincula AP, Reynolds RK, Burke WM. A minimally invasive technique for management of the large adnexal mass. J Minim Invasive Gynecol. 2006 Sep-Oct;13(5):476-9
TE D
13. Nagele F, Magos AL. Combined ultrasonographically guided drainage and laparoscopic excision of a large ovarian cyst. Am J Obstet Gynecol 1996;175:1377-8
AC C
EP
14. Oguz A, Karakaya E, Hakguder G, Olguner M, Secil M, Akgur FM. Laparoscopic excision of a giant ovarian cyst after ultrasound-guided drainage. Journal of Pediatric Surgery (2006) 41, E9-E11.
8
Figure Legends
RI PT
ACCEPTED MANUSCRIPT
Figure 1. Computed Tomography (CT) showing cyst-filled fluid of the abdomen
AC C
EP
TE D
M AN U
SC
Figure 2. H&E stain of resected paratubal cyst wall
9
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Fig. 1: Computed Tomography (CT) showing cyst-filled fluid of the abdomen
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Fig 2: H&E stain of resected paratubal cyst wall
S1083-3188(14)00375-1
DOI:
10.1016/j.jpag.2014.11.002
Reference:
PEDADO 1798
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 3 September 2014 Revised Date:
27 October 2014
Accepted Date: 13 November 2014
Please cite this article as: Asare EA, Greenberg S, Szabo S, Sato TT, Giant Paratubal Cyst in Adolescence: Case Report, Modified Minimal Access Surgical Technique and Literature Review, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.11.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Giant Paratubal Cyst in Adolescence: Case Report, Modified Minimal Access Surgical Technique and Literature Review Elliot A. Asare MD1, Sarah Greenberg MD1, Sara Szabo MD, PhD2, Thomas T. Sato MD3 1
RI PT
Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
2
Department of Pathology, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
3
AC C
EP
TE D
M AN U
SC
Department of Surgery, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
*Correspondence: Elliot Asare, MD Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave Milwaukee, WI 53226 o: 414-805-8632 m: 804-922-9267 E-mail: [email protected] 1
ACCEPTED MANUSCRIPT
ABSTRACT Background: Giant paratubal cysts are rare lesions that can present management
RI PT
challenges due to their enormous size. We present a modified minimally invasive approach for effective surgical management of giant paratubal cysts.
Case: A 19 year old female with worsening abdominal distension and metrorrhagia was
SC
diagnosed with a giant paratubal cyst. A modified, minimally invasive technique
designed to limit spillage of cyst fluid was successfully used for surgical management.
M AN U
Summary and Conclusion: 5500ml of cyst fluid was evacuated without spillage and near-complete excision of cyst was performed with preservation of adnexa. Preservation of the adnexa in adolescent females is critical and where minimally
AC C
EP
TE D
invasive approaches are possible, they should be employed.
2
ACCEPTED MANUSCRIPT
INTRODUCTION Giant paratubal or paraovarian cysts are rare lesions typically recognized during
RI PT
exploration following a clinical diagnosis of a suspected mesenteric or ovarian cyst. We present an adolescent female with a 5-kg paratubal cyst and describe the diagnosis, a modified minimal access surgical approach, pathology, and review of the literature.
SC
CASE
M AN U
Presentation
A 19-year-old G0P0 female presented with gradual abdominal distension over a period of eleven months, which she initially attributed to weight gain during her first year in college. Her abdominal distention was associated with metrorrhagia and progressive early satiety. She denied weight loss, fever, chills, night sweats, urinary tract
TE D
symptoms, or other gastrointestinal complaints. She was on no medications and there was no family history of ovarian neoplasms or polycystic ovarian disease.
EP
Clinical examination revealed a well-appearing, 74.5 kg, Tanner stage V female with notable non-tender protuberance of her abdomen and pelvis. Serum beta-HCG and
AC C
alpha-fetoprotein were normal. Abdominal and pelvic ultrasound demonstrated a 22.5 cm x 10.5 cm cystic abdominal mass, normal uterus, and bilateral ovaries. Subsequent CT scan image was obtained to delineate the origin of the cyst. This confirmed a homogeneous, unilocular, thin-walled cyst measuring 27cm x 23cm x 10cm (Figure 1). The cyst filled her pelvis and most of her abdominal cavity to the level of her liver with associated right hydronephrosis. There were no solid adnexal masses or pelvic lymphadenopathy. 3
ACCEPTED MANUSCRIPT
Surgical management Operative exploration was performed via a 6 cm suprapubic transverse incision. Clear
RI PT
pelvic fluid was aspirated and sent for cytology. To prevent spillage of cyst fluid into the peritoneal cavity, the end of a sterile ultrasound probe cover was fixed to the anterior cyst wall using 2-octyl cyanoacrylate (DermabondTM), and a percutaneous diagnostic peritoneal lavage catheter was inserted through the probe cover into the cyst using
SC
Seldinger technique; this was connected to suction. Approximately 5500 ml of clear,
M AN U
serous fluid was removed. The cyst had no attachments to the abdominal wall, intestine, or mesentery, and the decompressed cyst wall and attached structures were eviscerated. The uterus, right ovary and fallopian tube were normal. The cyst was densely fixed to an extremely elongated left fallopian tube and normal adjacent ovary. Near complete cyst excision was performed, and cyst wall remnants adherent to the
uneventful.
EP
Pathology
TE D
ovary and fallopian tube were left in situ to preserve these structures. Her recovery was
Microscopically, the well-developed paratubal cyst wall was lined with Mullerian
AC C
epithelium with underlying loose connective tissue stroma; there was a uniform dense collagenous wall (Figure 2). The cyst wall had a variable thickness fibrovascular layer intimately associated with smooth muscle bundles. There was no evidence of malignancy, borderline epithelium, vascular malformation, or other neoplasm. No ovarian stroma was found in any of the sections. Peritoneal fluid and cyst fluid cytology were negative for malignant cells.
4
ACCEPTED MANUSCRIPT
SUMMARY AND CONCLUSION Paraovarian or paratubal cysts arise from embryologic remnants located in the proximity
RI PT
of the broad ligament between the ovary and the fallopian tube .1 Variations in histopathology include mesonephric (Wolffian), mesothelial and paramesonephric
(Mullerian) origins.2 In a review of 79 females with paratubal cysts by Samaha and Woodruff, paramesonephric (Mullerian) histology was the most commonly encountered
SC
variant.2 Anatomic structures of Mullerian origin are the proximal two-thirds of the
M AN U
vagina, the uterus, cervix and fallopian tube.3 The secretory epithelium that lines Mullerian-derived structures accounts for the cystic dilatation of paramesonephric (Mullerian) cysts.2 Paramesonephric (Mullerian) cysts are responsive to hormonal stimulation, hence their observed incidence in post-pubertal females.2 The derivatives of
unlikely to form cysts.2,3
TE D
the mesonephric duct have muscular layers and minimal secretory activity hence
Incidence rates of paraovarian cysts are reported to be 17% to 33% for patients
EP
diagnosed with benign adnexal cysts .4 Paraovarian cysts are much more frequently encountered in women during the third and fourth decades of life compared to children
AC C
and adolescents. The incidence rate of neoplasm among reported cases of paraovarian cyst is 2-3% and includes cystadenocarcinoma, papillary carcinoma, and serous papillary neoplasms.5 Ovarian serous carcinoma accounts for 75-80% of ovarian epithelial carcinomas.7 The histologic appearance of ovarian serous tumors is similar to the glandular epithelial lining of the fallopian tube, leading to the proposition that serous epithelial carcinomas may arise from the distal fallopian tube.7 This proposition is of
5
ACCEPTED MANUSCRIPT
interest given the common embryologic origin of both the fallopian tube and paratubal cysts.
RI PT
Symptomatic complications of paraovarian cysts include hemorrhage, perforation, and torsion. Torsion may involve only the cyst itself, or the cyst and adjacent structures including the fallopian tube, broad ligament, or ovary. The risk of torsion appears
greater once cyst diameter exceeds 5 cm. Giant paraovarian cysts larger than 10 cm in
SC
diameter are extraordinarily unusual and anecdotal in the literature.8, 9,10 In 1964,
M AN U
Burnhill described the surgical management of a giant paraovarian cyst in a 38-year-old woman that required initial aspiration of 26 liters of fluid from the cyst prior to resection.10
Transpelvic or transvaginal ultrasound and axial imaging aid diagnosis and operative
TE D
planning; however, definitive diagnosis may require exploration to confirm cyst origin. The differential diagnosis of homogeneous, unilocular cysts during adolescence that fill the entire peritoneal cavity includes ovarian cyst, paraovarian cyst, mesenteric cyst, and
EP
abdominal or pelvic lymphangioma. Generally, these may be readily differentiated on imaging studies from more complex, muliticystic lesions caused by mucinous
AC C
carcinomatosis, peritoneal inclusion cyst, pancreatic pseudocyst, or echinococcal cystic disease. We utilized controlled cyst aspiration designed to avoid spillage and potential risk of peritoneal seeding in the extremely rare event of malignant neoplasm. Additionally, this approach allows for delivery of the cyst wall and adjacent structures through a single, limited incision. Pelosi and Pelosi were first to describe a technique in which through an anterior abdominal wall minilaparotomy, a surgical adhesive was used to attach a plastic wound dressing to the giant cyst wall and the cyst was drained with 6
ACCEPTED MANUSCRIPT
care to avoid intraabdominal spillage prior to resection.11 A similar minimal access approach was described by Rhode et al in which a large bore needle was used to decompress cyst through a 2-octyl cyanoacrylate (DermabondTM) dressing followed by
RI PT
cystectomy.12 Other minimally invasive techniques that involve cyst decompression prior to resection have subsequently been described.13, 14 Our approach builds on these
previously described techniques but our use of a sterile ultrasound probe cover as a
SC
conduit through which aspiration was done drastically reduced any chance of
M AN U
intraabdominal spillage.
Giant parovarian or paratubal cysts during adolescence are exceedingly rare and definitive preoperative diagnosis is challenging. Factors including patient symptoms, cyst size, appearance on imaging, and suspicion for malignancy may help guide surgical management. A single, limited incision technique with deliberate, protected
with these giant cysts.
EP
REFERENCES:
TE D
cyst aspiration prior to extracorporeal examination and excision is particularly useful
AC C
1. Barloon TJ, Brown BP, Abu-Yousef MM, Warnock NG. Paraovarian and paratubal cyst: preoperative diagnosis using transabdominal and transvaginal sonography. J Clin Ultrasound 1996;24: 117-122 2. Samaha M, Woodruff JD. Paratubal cysts: Frequency, histogenesis, and associated clinical features. Obstet Gynecol 1985;65:691-694 3. Oldham KT, Colombani PM, Foglia RP, Skinner MA. Principles and Practice of Pediatric Surgery. Second Edition. Lippincott Williams & Wilkins. 2005. p1606, p1622. 4. Okada T, Yoshida H, Matsunaga T, Koucihi K, Ohtsuka Y, Takano H, Horie H, Ohnuma N. Paraovarian cyst with torsion in children. J Pediatr Surg 2002;37:937-940
7
ACCEPTED MANUSCRIPT
5. Honore LH, O’Hara KE. Serous papillary neoplasms arising in paramesonephric parovarian cysts. A report of eight cases. Acta Obstet Gynecol Scand 1980;59(6): 525-8
RI PT
6. Berek JS, Hacker NF. Berek and Hacker’s Gynecologic Oncology. Fifth Edition. Lippincott Williams & Wilkins. 2010. P443-444. 7. Kostov M, Mijovic Z, Mihailovic D. Giant parovarian cyst in a child complicated with torsion. Vojnosanit Pregl 2008;65(11):843-6 8. Letourneur B, Grandjean S, Richard P, Parant O. Management of a giant parovarian cyst. Gynecol Obstet Fertil 2006;34(3):239-41
SC
9. Cevrioglu AS, Polat C, Fenkci V, Yilmazer M, Yilmaz S, Dilek ON. Laparoscopic management following ultrasound-guided drainage in a patient with giant paraovarian cyst. Surg Endosc 2004;18:346
M AN U
10. Burnhill MS. Giant parovarian cyst: Report of a case. Obstet Gynecol 1965;26:275-6 11. Pelosi MA II, Pelosi MA III. A novel minilaparotomy approach for large ovarian cysts. OBG Management. February 2004: 17-30 12. Rhode JM, Advincula AP, Reynolds RK, Burke WM. A minimally invasive technique for management of the large adnexal mass. J Minim Invasive Gynecol. 2006 Sep-Oct;13(5):476-9
TE D
13. Nagele F, Magos AL. Combined ultrasonographically guided drainage and laparoscopic excision of a large ovarian cyst. Am J Obstet Gynecol 1996;175:1377-8
AC C
EP
14. Oguz A, Karakaya E, Hakguder G, Olguner M, Secil M, Akgur FM. Laparoscopic excision of a giant ovarian cyst after ultrasound-guided drainage. Journal of Pediatric Surgery (2006) 41, E9-E11.
8
Figure Legends
RI PT
ACCEPTED MANUSCRIPT
Figure 1. Computed Tomography (CT) showing cyst-filled fluid of the abdomen
AC C
EP
TE D
M AN U
SC
Figure 2. H&E stain of resected paratubal cyst wall
9
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Fig. 1: Computed Tomography (CT) showing cyst-filled fluid of the abdomen
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Fig 2: H&E stain of resected paratubal cyst wall
