(2) 17-Year-Old with Large Partial Intraperitoneal and Retroperitoneal Paratubal Cyst

Background: Paratubal cysts comprise approximately 10% of all adnexal masses and are usually benign in nature. The preferential treatment option for symptomatic lesions is a fertility-sparing minimally invasive surgery whenever possible.

Case: Pediatric and adolescent gynecology (PAG) was consulted on a 17-year-old after presenting to her pediatrician with intermittent 6/10 dull abdominopelvic pain. She denied early satiety, abdominal fullness, nausea, vomiting, or changes in bowel habits. A pelvic ultrasound was performed by per primary provider noting a 9.5cm left adnexal cystic mass. She was taken to the operating room by the PAG provider for a diagnostic laparoscopy during which gynecologic oncology (Gyn/Onc) was consulted intraoperatively because a visible 1-2cm left paratubal cyst appeared to be contiguous with a much larger 6-7cm cystic mass that had intraperitoneal and retroperitoneal components with adhesions to the colon and pelvic sidewall. The decision was made to end the operation to allow for additional imaging (Figure 1). Gyn/Onc reviewed her postoperative images showing a 10cm unilocular lesion in the left ovary with predominant intraperitoneal location despite limited visualization of said cystic lesion during her first procedure. Given their low clinical suspicion for malignancy, Gyn/Onc took the patient for a subsequent robotic cystectomy with final pathology identifying negative pelvic washings and an 8.6cm benign serous epithelial lined cyst consistent with a paratubal cyst. Despite no prior abdominal surgeries or history of sexual activity, the mass was adherent to the pelvic sidewalls, bowel, and epiploica. The patient was seen postoperative and was achieving all appropriate milestones.

Comments: Despite preoperative ultrasound imaging, the PAG providers in this case recognized the unique anatomic variation and unexpected adhesive disease noted at the time of surgery and promptly consulted Gyn/Onc intraoperatively. Additional imaging allowed for further mass characterization and surgical planning. The Gyn/Onc team also took the initiative to obtain pelvic washings, a beneficial step to consider any time there is risk of malignancy or potential spillage during a case.