Obstetrics and Gynecology - A.M. Hromova 2000

Benign Tumors of the Female Reproductive Organs
Benign Ovarian Tumors
Ovarian Cysts

Retention ovarian cysts are formations that occur As a result of fluid accumulation within a specific cavity. The enlargement of the cyst is driven not by the proliferation of cellular elements, but by the accumulation of fluid, which is a Blood Plasma transudate. This distinguishes cysts from true ovarian neoplasms, known as cystomas.

Follicular cyst

Follicular ovarian cysts are the most frequently observed type. There are two primary theories regarding their origin. The first points to a hormonal imbalance in the body—specifically, a decrease in the estrogenic function of the Ovaries—which leads to an elevation in gonadotropic hormone levels, altering the LH-to-FSH ratio in favor of the latter. This is supported by the frequent concurrence of cysts with uterine myomas, which are also accompanied by hormonal disruptions. The second theory attributes The Development of cysts to changes occurring in the ovaries during inflammatory processes of the uterine appendages. In this context, pelvic congestion and the development of peri-oophoritis play a significant role.

A follicular cyst goes through several stages in its development. Stimulated by FSH, the ovarian follicles begin to increase in size, with one follicle growing noticeably more than the others. The resulting cyst enlarges at the expense of the follicular cavity. These cysts can originate from atretic and persistent follicles. The cavity of the cyst is filled with a clear, transparent fluid, and its inner surface is lined with granulosa Cells. As growth continues, the inner lining of the cyst thickens, the cells enlarge, the nuclei swell, while the outer lining remains largely unchanged. The subsequent stage of development is characterized by dystrophic and atrophic changes: the epithelium thinned out, desquamates, and eventually disappears. Protoplasmic vacuolization, pyknosis, and nuclear breakdown occur. Similar changes take place in the inner lining. As a result, the cyst transforms into a relatively small, thin-walled, smooth-walled ovarian formation. The content of follicular cysts is a clear, lemon-yellow fluid devoid of mucus or mucin, occasionally tinged with blood. They are invariably unilocular; the presence of multiple chambers strongly suggests an ovarian cystoma, although several cysts can occasionally develop simultaneously in an Ovary, gradually enlarging, merging, and mimicking a multilocular Structure. Follicular cysts are hormonally inactive.

Clinical presentation and Diagnostics

An uncomplicated, small follicular cyst is typically asymptomatic and is usually discovered during a routine gynecological examination. Bimanual examination reveals a relatively small, smooth-surfaced, mobile, and painless mass of firm-elastic consistency located laterally and anteriorly to the Uterus. Symptoms arise when the cyst pedicle undergoes torsion or when adjacent Organs are compressed, manifesting as lower back pain, a feeling of heaviness in the lower abdomen, and urinary symptoms. The patient's history often reveals previous inflammatory processes or menstrual irregularities. To confirm the Diagnosis, Ultrasound examination and laparoscopy are performed.

Surgical Treatment is indicated. The Procedure involves enucleating the cyst while preserving healthy ovarian tissue, which is particularly crucial for women of reproductive age.

Corpus luteum cysts are relatively rare. Their development is linked to the fact that after ovulation, the follicular cavity fails to collapse and fill completely with lutein cells; instead, it persists and becomes distended with serous fluid.

Macroscopically, corpus luteum cysts differ from follicular cysts by having thicker walls and a yellow, folded inner surface. Their content is a clear, light fluid, occasionally admixed with blood. They feature a smooth surface, an elastic consistency, and a small size (averaging up to 5 cm in diameter; larger ones are extremely rare). Microscopically, corpus luteum cysts are characterized by the presence of lutein cells arranged in sheets or discrete groups.

Two Cell types are distinguished: lutein and theca-lutein cells. Lutein cells are large and polygonal with round nuclei and transparent protoplasm. Theca-lutein cells are located externally to the lutein layer and lack a distinct boundary with the underlying Connective Tissue; they are smaller than lutein cells and possess darker nuclei. Histological studies have shown that the lutein cells of corpus luteum cysts undergo stages of proliferation, vascularization, maturation, and regression. During the proliferation phase, the cells are small and actively growing, and the theca-lutein cells are well-defined. In the vascularization phase, capillaries and connective tissue grow inward from the theca interna. During the maturation phase, the lutein cells assume a polygonal shape with transparent Cytoplasm, while the theca-lutein cells are less prominent, persisting as a peripheral layer. In the regression phase, the protoplasm of the lutein cells loses its transparency, the nuclei undergo pyknosis, and connective tissue proliferates, gradually replacing the lutein cells while the number of theca-lutein cells increases sharply. Concurrently with the regression of lutein cells and their replacement by connective tissue, the cyst cavity gradually disappears and is replaced by connective tissue.

Clinical presentation and diagnostics

There are no characteristic Clinical Features specific to the course of a corpus luteum cyst. Patients may experience Amenorrhea lasting from 2–3 weeks to 2–3 months, which can be accompanied by typical Signs of Pregnancy (nausea, food cravings, breast tenderness). Bimanual examination reveals unilateral enlargement of the appendages, with the cyst characteristically appearing or enlarging during the second phase of the Menstrual cycle.

Treatment: When a corpus luteum cyst is suspected, one should not rush into surgical intervention. Such patients are subject to clinical follow-up and should be monitored over the course of three menstrual cycles. During this period, the corpus luteum cyst may resolve spontaneously. If the cyst does not decrease in size or shows a tendency to grow, surgical intervention is necessary, as ruling out a true ovarian neoplasm can be quite difficult.

Theca-lutein cysts are characteristic of trophoblastic disease (Hydatidiform Mole or Choriocarcinoma). These cystic formations develop under the stimulating influence of human chorionic gonadotropin—which contains a high concentration of luteinizing hormone—on the theca tissue of the ovary. Theca-lutein cysts present as bilateral formations with a smooth surface and a brownish capsule. Their content is liquid, occasionally viscous, and yellow or brownish-red in color. Even when large, theca-lutein cysts gradually decrease in size following the evacuation of a hydatidiform mole or the successful treatment of choriocarcinoma. Ovarian function is restored, and normal subsequent pregnancies are possible.

In recent years, for the management of hydatidiform moles and choriocarcinomas, puncture of the cysts with aspiration of their contents has been recommended to accelerate tumor regression. In cases where the cysts persist for several months, the onset or metastasis of choriocarcinoma must be considered primarily.

Paraovarian cyst

Paraovarian cysts develop from embryonic remnants of the mesonephros (Wolffian body), which appear as blind-ended tubules located between the fallopian tube and the ovary within the leaves of the mesosalpinx. Normally, these tubules undergo obliteration and present as vestigial structures. However, in some women, they may undergo cystic dilation due to secretory activity. They are primarily located within the ligaments. The wall of a paraovarian cyst consists of connective tissue, and its inner surface is smooth and lined with a single layer of columnar or squamous epithelium.

The cysts are unilocular with thin walls and are filled with a clear fluid that is low in protein and devoid of mucin. Their size varies widely, ranging from a few centimeters to the size of a newborn's HEAD.

Paraovarian cysts are spherical or oval in shape. The ovary is typically not involved in the pathological process and is situated laterally and inferiorly to the cyst, while the fallopian tube is stretched across the cyst's surface.

Clinical presentation and diagnostics

Patients with small paraovarian cysts are typically asymptomatic, and menstrual function remains unaffected. Large cysts may cause pain and urinary symptoms. Bimanual examination reveals a firm-elastic, relatively immobile mass situated between the uterus and the ovary due to its intraligamentary Location.

Surgical treatment is indicated. The procedure involves enucleating the cyst while making every effort to preserve the ovary and fallopian tube. Because paraovarian cysts alter the topography of Internal Organs, special care must be taken when ligating and dividing the vessels supplying the cyst. Recurrence following excision is exceedingly rare, and malignant transformation is exceptionally uncommon.

Diagnosis of ovarian tumors

Diagnosing tumors and tumor-like formations of the internal genitalia is often challenging because the disease remains asymptomatic for a considerable period, lacking pathognomonic Complaints. One of the most consistent symptoms is the late onset of pain localized in the tumor area, lower abdomen, or lower back. Abdominal enlargement and dysfunction of adjacent organs (urinary symptoms, defecation disorders) may occur, later joined by general constitutional disorders such as malaise, fatigue, and weight loss. It should be kept in mind that these symptoms can accompany both benign and malignant ovarian lesions.

In diagnosing ovarian tumors, patient history, abdominal inspection and Palpation, and bimanual examination are of paramount importance. These Methods help determine the size, consistency, surface characteristics, and LOCATION OF THE tumor, as well as its topographical relationship to adjacent organs.

Ovarian cysts are thin-walled formations with a firm and elastic consistency; they rarely reach large sizes and are typically located anterior or lateral to the uterus. Cystic formations are painless upon palpation, have a stalk, and consequently possess considerable mobility.

In the case of a papillary cystoma, the uterus is usually displaced upward toward the Pubic Symphysis by a tumor originating from one or both ovaries. The tumor is located posterior to the uterus and has a firm, elastic, and sometimes uneven consistency with areas of induration. When papillary growths are present on the lower pole of the tumor and on the Peritoneum of the rectouterine pouch, an induration can be palpated that gives the impression of fine nodularity. The mobility of a papillary cystoma is often limited due to its intraligamentous growth.

When a pronounced everting form of papillary cystoma is present—where large masses of cauliflower-like papillary proliferations exceed the size of the cystic tumor itself—bimanual examination reveals small tumors with an uneven surface behind and lateral to the uterus. In one of the areas, it is possible to palpate "crunching" formations larger than the tumor, of a bizarre shape and without clear boundaries.

A pseudomucinous cystoma features a thick capsule and an uneven, nodular surface due to its multilocular structure.

Comparing anamnestic data with the results of a gynecological examination enables an accurate diagnosis in many patients. However, this is often insufficient. Additional Diagnostic Methods must be employed, such as Ultrasonography, laparoscopy, culdoscopy, radiography, bicontrast gynecography, biological tests for urinary human chorionic gonadotropin, and hormonal studies.

One of the modern methods is ultrasound examination of the internal genital organs. Before the procedure, the bowels and bladder must be emptied. The patient is placed supine on a horizontal surface, and if necessary, positioned in the Trendelenburg position or on her side. If a fluid-filled tumor-like formation lies beneath the anterior abdominal wall, the ultrasound energy passing unimpeded through the anterior abdominal wall and the anterior wall of the tumor propagates further through the fluid content and reflects off the posterior wall of the tumor. In this case, the entire contour of the tumor is visible on the echogram. If a multilocular formation is present, the septum of the cystic cavity can be seen on the echogram. If a solid tumor that strongly absorbs ultrasound energy is located beneath the anterior abdominal wall, the screen displays only a cross-section of the anterior abdominal wall and the adjacent portion of the tumor, followed by a rapid attenuation of the signal.

One of the simple auxiliary diagnostic methods is plain radiography; however, a standard radiograph reveals only formations that attenuate X-rays (calcified nodes, dermoids containing Teeth or bones). To clearly outline the external contour of internal pelvic formations, an additional contrast medium (air, oxygen, or carbon dioxide) must be introduced into the Abdominal cavity, and imaging is performed against this Background.

On a radiograph performed under pneumoperitoneum conditions, the bony pelvic ring and the shadows of the rectum and Urinary Bladder are clearly visible. The uterus stands out as a dense oval shadow. Shadows corresponding to the broad ligaments and fallopian tubes extend from its contours on both sides. The ovaries are identified as dense oval shadows near the pelvic walls. As a rule, tumors located in the minor pelvis and the displacement of internal genital organs are clearly visible against the background of the introduced gas.

Tumors originating from the ovaries are visualized as round or oval shadows of varying sizes with distinct and smooth contours. In tumor-like formations fused with the uterus, the radiograph reveals a shadow with polycyclic contours, which may be interpreted as uterine myoma. In cases combining uterine myoma and an ovarian cyst, the shadows of the myomatous nodes and the shadow of the ovarian tumor-like formation are both visible.

The diagnosis of a paraovarian cyst can be established only if the shadow of an unchanged ovary is clearly visible next to the cyst's shadow. If the ovarian shadow is absent, it is impossible to precisely determine the Water/144.html">Origin of the cyst. On a radiograph, a tubo-ovarian cyst appears as an irregular oval shadow extending from the uterine cornus.

In the presence of an inflammatory process, radiographs show shadows that merge with the pelvic walls. In cases of polycystic ovaries (sclerocystic ovaries), an unmagnified uterus is visible alongside spherical or oval ovaries with clear contours whose sizes approach that of the uterus (normally, their size is 1/3 of the uterus).

Contraindications for diagnostic imaging include decompensated cardiovascular diseases, cardiopulmonary failure, Hypertension, pronounced adhesive disease in the abdominal cavity, acute and subacute inflammatory processes in the abdominal cavity, acute infectious diseases, advanced age, the menstrual period, and large tumor sizes.

In recent years, endoscopic diagnostic methods have gained major importance. These include laparoscopy and culdoscopy. Endoscopic examination involves inserting an optical instrument into the abdominal cavity to perform the necessary visual inspection.

Endoscopic examination is performed for the Differential diagnosis between tumors of the uterus and its appendages, between tumors and inflammatory processes of the uterine appendages, to confirm the presence of a pelvic tumor or sclerocystic ovaries, and in cases of suspected Ectopic Pregnancy or Developmental anomalies of the internal genital organs.

Inspection of the pelvic organs can be performed via two routes:

1) through the anterior abdominal wall (laparoscopy);

2) through the posterior vaginal fornix (culdoscopy).

The choice of the insertion site for the optical instrument is determined individually and depends on the size of the formation, the patient's age, and her general condition.

Contraindications are divided into two groups: general and local. General contraindications include cardiac decompensation, pulmonary failure, severe general condition, presence of an infectious disease, menstruation, and pregnancy. During menstruation, there is an increased Blood supply to the pelvic organs and a slight decrease in blood clotting. Local contraindications include adhesive disease in the abdominal cavity, meteorism (as a distended bowel carries the risk of injury), and severe obesity. Culdoscopy should not be performed if the tumor is located low in the rectouterine pouch, if adhesions and scars are present, in the presence of colpitis, or in elderly women with marked vaginal stenosis.

Before undergoing endoscopy, the patient must evacuate her bowels using an enema on the evening before and the morning of the procedure. Immediately prior to the procedure, the urinary bladder is emptied, and 20–30 minutes before the examination, 1 ml of a 2% promedol solution is administered subcutaneously. The examination is conducted under local infiltration anesthesia using a 0.5% novocaine solution; general anesthesia may be used in selected cases.

When an ovarian cyst is present, a round or oval formation of a gray or bluish color with transparent contents is visible. In the case of an ovarian cystoma, whitish formations with a capsule, sometimes with papillary outgrowths, can be observed.

A paraovarian cyst is visualized as a bluish cystic formation with the fallopian tube spread across its surface. An unchanged ovary is visible nearby.

Endometrioid cysts present as whitish formations with blue or brownish areas, featuring a dense capsule, an uneven surface, and are frequently surrounded by numerous adhesions.

The picture in sclerocystic ovaries is quite characteristic. The uterus is bright pink and occupies a midline position. The ovaries are bilaterally enlarged to the size of a large plum or chicken egg, with a whitish, shiny surface; small bluish cysts are occasionally visible.

In the presence of a chronic inflammatory process, adhesions of various types are visible in the form of cords or broad sheets that encase the pelvic organs.

It is not always possible to determine the true size of a tumor during laparoscopy, as its actual dimensions may appear enlarged or reduced depending on the distance between the optical device and the lesion. Therefore, the primary objective is to confirm the presence of a tumor and identify its site of origin. An accurate diagnosis frequently requires combining several investigative methods, all of which serve as a valuable Complement to bimanual examination findings.

Management of Ovarian Tumors

Nowadays, the principle that any patient diagnosed with an ovarian tumor requires mandatory surgical treatment is universally accepted, and its validity has been confirmed by numerous clinical observations. This approach is dictated by the fact that neither malignant nor benign tumors undergo spontaneous regression, and delaying their removal can lead to a series of complications.

Only corpus luteum cysts, which are quite rare, undergo spontaneous regression and do not require surgical intervention. However, differentiating a corpus luteum cyst from other cystic lesions is extremely difficult. Consequently, young patients should be monitored over the course of 2-3 menstrual cycles, during which time a corpus luteum cyst may resolve on its own. If the cystic mass does not decrease in size, surgery must be performed. The extent and Nature of the surgical procedure are determined by the patient's age and the CHARACTERISTICS OF THE tumor.

In young women with an ovarian cyst, it is often possible to enucleate the cyst while preserving healthy ovarian tissue. For women of reproductive age who have benign tumors affecting one ovary, unilateral oophorectomy or salpingo-oophorectomy is performed. If there is evidence suggesting malignant transformation of the cystadenoma, a total Hysterectomy with bilateral salpingo-oophorectomy is indicated, regardless of the patient's age. When a tumor is detected during menopause, a total hysterectomy with bilateral salpingo-oophorectomy is likewise required.

Pregnancy can occur concurrently with ovarian tumors. During pregnancy, tumors frequently exhibit accelerated growth and an increased risk of ovarian torsion. Therefore, the presence of an ovarian tumor during pregnancy warrants surgical intervention.

For small, benign tumors—especially in young patients—a Pfannenstiel incision may be used. However, in patients with a thick anterior abdominal wall, large tumors, or fixed/poorly mobile masses, a lower midline laparotomy is the most rational approach, which can be extended superiorly if necessary.

Upon opening the abdominal cavity, it is necessary to assess the pathological situation, evaluate The Nature of the tumor, and determine its anatomical relationships with the pelvic walls and adjacent organs. For a pedunculated tumor, oophorectomy is performed. To do this, the tumor is gently exteriorized into the wound using a surgical sponge. If this is not feasible, the cystadenoma is delivered manually. Kocher clamps are applied to the utero-ovarian ligament, the suspensory ligament of the ovary, the mesosalpinx, the tumor itself, and the fallopian tube near the uterine cornu, after which the Tissues are divided. An interrupted catgut suture is placed on the uterine cornu, and the clamp is replaced with a ligature. Peritonization is achieved using a continuous catgut suture with the round ligament of the ovary, completely covering the ligated stump and isolating it from the abdominal cavity. The peritoneal cavity is then lavaged, and a final count of surgical Sponges and instruments is performed. The anterior abdominal wall is closed in layers: the peritoneum and Muscles with a continuous catgut suture, the aponeurosis with interrupted silk sutures, and the subcutaneous tissue with catgut sutures. The Skin is closed with silk sutures or Michel clips. The volume of blood loss must be documented, and a detailed Description of the removed surgical specimen must be provided.

Salpingo-oophorectomy—the removal of the uterine appendages (ovary and fallopian tube)—is performed as follows: a Kocher (or Mikulicz) clamp is applied to the stretched mesosalpinx. Excision of the cystadenoma begins by placing clamps and dividing the suspensory ligament of the ovary, followed by the transection of the fallopian tube and the utero-ovarian ligament. The clamps are subsequently replaced with silk ligatures, and peritonization is performed using the round ligament of the uterus.

Complications that may arise from benign ovarian tumors include:

1. Torsion of the tumor pedicle, Hemorrhage into the capsule, and necrosis.

2. Rupture of the tumor capsule and its Blood Vessels, accompanied by hemorrhage.

3. Suppuration of the tumor resulting in a pelvic abscess, which may rupture into the peritoneal cavity, urinary bladder, rectum, or, more rarely, the Vagina.

4. Compression of adjacent organs leading to impaired function.

5. Malignant transformation of the cystadenoma.

In summary, ovarian tumors rank second in frequency among tumor-like conditions of the FEMALE Reproductive System. The Challenge of early diagnosis lies in the asymptomatic course of the disease during its initial stages, as well as difficulties in differentiating them from malignant processes. These factors necessitate the Surgical Treatment of such tumors. This approach promotes patient recovery and forms the foundation for preventing malignant Diseases of the FEMALE REPRODUCTIVE ORGANS.