Postoperative scar endometriosis: the clinical course, diagnosis, treatment, and the morphological examination of surgical material

Abstract

BACKGROUND: Postoperative scar endometriosis is diagnosed in 0.03–1.5% of women and is 0.42–4.0% of the total number of endometriosis lesions. The increase in the frequency of surgical delivery and the difficulties of early clinical diagnosis determine the relevance of clinicopathologic analysis of postoperative scar endometriosis.

AIM: The aim of this study was to conduct a comprehensive comparative analysis of the clinical course, diagnostic criteria, results of surgical and combined treatment, as well as morphological and morphofunctional features of postoperative scars endometriosis.

MATERIALS AND METHODS: We analyzed complaints, anamnesis, general clinical, gynecological and instrumental examination data, as well as results of the morphological examination of the surgical material from 21 patients with postoperative scar endometriosis. Immunohistochemical study of the surgical material was performed according to the avidin-biotin complex method using monoclonal mouse antibodies to alpha-smooth muscle actin (Dako, Denmark).

RESULTS: The average age of patients with postoperative scar endometriosis was about 33.6 ± 6.3 years. In 19 out of 21 patients (90.47%), this pathology occurred in the scar after caesarean section. The main clinical manifestation of the disease was pain syndrome. All patients complained of periodic pain in the area of the postoperative scar, which worsened on the eve and during menstruation. According to its nature and intensity, the patients characterized the pain as dull (33.3%), aching (14.3%), paroxysmal (19.1%), or “twitching” (33.3%). In some cases (28.6%), the pain syndrome was accompanied by nausea and vomiting. Many women (71.4%), in addition to the pain, noted the appearance of dark brown (bloody) discharge from the scar during menstruation. In macro- and microscopic examination, postoperative scar endometriosis foci formed nodes of different sizes without a clear capsule. This was due to proliferation of connective tissue fields found in all observations with a large number of collagen fibers located around and between heterotopias. Immunohistochemical study of postoperative scar endometriosis revealed perifocal proliferation of myofibroblasts, which surrounded endometrioid heterotopias in the form of “couplings” and was characterized by positive expression of alpha-smooth muscle actin. Concentric myofibroblast proliferates in the form of nodules were found in the cytogenic stroma of endometriosis foci.

CONCLUSIONS: Early diagnosis and treatment of endometriosis are important in terms of preventing the fibrosis and sclerosis of the affected tissues and organs, which lead to their deformation and dysfunction.

Keywords

extragenital endometriosis / postoperative scar endometriosis / anterior abdominal wall / caesarean section / alpha-smooth muscle actin

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Pechenikova V.A., Akopyan R.A., Danilova A.S., Petrovskaia N.N.