Search

An 8-year-old female spayed dog was presented due to simultaneous inability to defecate and urinate. During digital rectal examination a smooth, rounded, firm-elastic mass was detected. Laboratory results showed a 6-fold elevation of serum lactate dehydrogenase activity. Ultrasonographic, radiographic and computed tomography findings raised the suspicion of a leiomyoma. An ultrasound-guided fine needle aspiration biopsy was performed under mild sedation but cytologic evaluation was inconclusive. During laparotomy the mass was located at the colorectal transition. It was completely removed while keeping the intestinal wall intact. The results of the histopathological examination and immunohistochemistry confirmed the initial tentative diagnosis of a leiomyoma. Postoperatively the patient was able to pass urine and feces spontaneously. Six months later the dog presented clinically unremarkable. Abdominal ultrasound and rectal examination exhibited no signs of recurrence. Lactate dehydrogenase activity was only marginally increased., Competing Interests: Die Autoren bestätigen, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Magnetic Resonance-guided focused ultrasound (MRgFUS; Syn.: HIFU = high intensity focused ultrasound) is a safe and effective thermoablative technique to treat fibroid-related symptoms. The evidence is limited due to a lack of randomized trials. The indication for treatment by MRgFUS are symptomatic uterine fibroids. This consensus paper covers criteria to measure success, contraindications, side effects and complications of MRgFUS treatment. The role of MRgFUS in the setting of family planning is part of this publication. KEY POINTS:: · MRgFUS therapy should be based on a clear understanding of the aim of treatment and the wish of the patient.. · Success of MRgFUS/HIFU treatment should be judged by the degree of improvement (alleviation) or disappearance of fibroid-related symptoms.. · The indication for treatment by means of MRgFUS/HIFU is based on a gynecological examination incl. ultrasound performed by a specialist. Necessary prerequisite for MRgFUS/HIFU treatment is a contrast-enhanced MRI of the pelvis.. · A number of more than 5 fibroids (leiomyomata) limits the success of MRgFUS/HIFU therapy; the indication to treat fibroids exceeding 10 cm in diameter should be reviewed critically.. · A recommendation for the treatment of fibroids by MRgFUS to patients who seek to conceive cannot be given based on the current state of knowledge.. CITATION FORMAT: · Kröncke T, David M. MR-Guided Focused Ultrasound in Fibroid Treatment - Results of the 4th Radiological-Gynecological Expert Meeting. Fortschr Röntgenstr 2019; 191: 626 - 629., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Leiomyomas of the esophagus are rare tumors but the most common benign lesion of the esophagus originating from smooth muscle cells. The symptoms are mainly determined by the size of the tumor and are caused by dysphagia and/or retrosternal pain. The majority of patients are however asymptomatic. The diagnostics include esophagoscopy, endosonography and chest computed tomography. Surgery is considered the treatment of choice and ideally involves enucleation of the tumor but may lead to esophagectomy. In addition to the classical open procedures, minimally invasive procedures are also used. Regardless of the selected procedure, a lesion of the mucosa should be avoided., Objective: A review of the literature on thoracoscopic and robotic resections in the treatment of leiomyomas was carried out and an illustration of a clinical case is presented., Material and Methods: A review of minimally invasive surgical treatment of esophageal leiomyomas is presented. The literature search was carried out in PubMed for publications of thoracoscopic and robotic-assisted thoracic enucleation of leiomyomas of the esophagus. In addition, the robotic-assisted thoracic enucleation of a horseshoe-shaped leiomyoma in the middle third of the esophagus is described., Results: The enucleation of the esophageal leiomyoma was carried out through a right-sided robotic-assisted operation with one lung ventilation. The surgery time was 143 min. There were no intraoperative or postoperative complications. On the 3rd postoperative day a light diet was started and the thorax drainage was removed. Histopathology confirmed a leiomyoma. The patient was discharged on the 5th postoperative day and free of complaints., Conclusion: Robotic-assisted surgery for leiomyomas of the esophagus is a safe procedure. Taking the available data into account, robotic-assisted thoracic enucleation of leiomyomas was characterized by less mucosal lesions, general complications and a lower conversion rate as well as a shorter hospital stay compared to classical thoracoscopic enucleation. Thus, robotic-assisted surgery can be the method of choice for leiomyomas of the esophagus.

Purpose: Purpose of this paper to present results of a group of 21 consecutive patients who underwent uterine artery embolization (UAE) immediately before myomectomy. Surgical myomectomy can lead to a substantial blood loss in case of large or multiple tumors due to the hypervascularization of the tumors. This may lead to multiple blood transfusion or hysterectomy. In cases were the preservation of the uterus is demanded, pre-operative embolization could reduce the risk of substantial bleeding., Materials and Methods: Between January 2011 and March 2016, 21 patients underwent UAE 24 hours before myomectomy. All patients were asked by questionnaire about post-surgical follow-up, complications, the length of the scar, satisfaction and improvement of symptoms. Data of the operation and embolization were retrospectively assessed., Results: UAE could be performed in all patients without complications. Mean diameter of the largest myoma was 12.7 ± 3.2 cm, primary preservation of the uterus succeeded in all cases. In none of the cases a perioperative blood transfusion was necessary. One patient underwent hysterectomy in another hospital after primary successful resection, one patient received transfusion of 2 bags of red blood cell concentrate during her stay in hospital.11 of 21 patients responded to the questionnaire. 10 of 11 had subjective symptom improvement. Mean inability to work was 31 days, the mean self-measured length was 12 cm. 9 of 11 patients would recommend the procedure, one patient was in the second trimester of pregnancy., Conclusion: Preoperative uterine artery embolization facilitates a safe and uterus-preserving myomectomy in patients with very large or multiple fibroids., Key Points: · Uterus-preserving myomectomy can be used in cases of large uteri or with multiple fibroids with low amount of blood loss.. · The combination of preoperative embolization and subsequent myomectomy may be a therapeutic option in cases of infertility due to a fibroid-induced uterine deformation.. · Good interdisciplinary cooperation is essential for sustainable results in this complex group of patients.., Citation Format: · Schnapauff D, Russ M, Kröncke T et al. Analysis of presurgical uterine artery embolization (PUAE) for very large uterus myomatosus; patient's desire to preserve the uterus; case series and literature review. Fortschr Röntgenstr 2018; 190: 616 - 622., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

The scrotal leiomyoma is a rare benign tumour, deriving from the smooth muscle. This tumour entity constitutes a differential diagnosis to malignant testicular tumours. Up to now, only 8 cases have been reported in the literature. We report on a 63-year-old European patient, presenting in our clinic for further treatment with a now monstrous mass of the left testis (about 8 kg) that has been growing for about 30 years, After partial scrotalectomy and orchiectomy pathological analysis confirmed a left-sided leiomyoma of the testicular/paratestical tissue. This case shows that even rare tumours should be included in the differential diagnosis of a testicular tumour., (© Georg Thieme Verlag KG Stuttgart · New York.)

The surgical treatment of uterine fibroids represents an important column in the therapy of this disease. Aim of this study was to find out preoperative factors that influence the treatment success of a minimal-invasive surgical -therapy.In a retrospective study 228 patients were assessed. Measures comprised questions on the decision for surgery, satisfaction with the treatment, and the EQ-5D as a measure of QoL.The sample revealed an overall satisfaction with treatment and high QoL. A better postoperative contentment and QoL in patients who felt well informed about the surgical methods and who felt secure with their decision for a specific surgery was found.Regardless of the surgical method, the preoperative consultation and the certainty of the decision turned out to be determinants of the patients' postoperative contentment and QoL. The counseling gynecologist has an essential part in the patients' decision for the treatment., (© Georg Thieme Verlag KG Stuttgart · New York.)

An unusual transmural tumor-like myxoid lesion was found in the cervix of the hysterectomy specimen of a 43-year-old woman. Histochemically the lesion was positive for alcian blue but negative for periodic acid Schiff (PAS) staining. The immunohistochemical staining showed positive reactions for CD10 and CD34 but negative reactions for actin. The incidence of this lesion is unknown. Isolated involvement of the cervix as in the current case has not been described before. Several theories have been put forward for the pathogenesis of this lesion: 1) transfer of subepithelial tissue from the lower genital tract in the cervical region, 2) sequelae of progesterone therapy, 3) association with an autoimmune disease and 4) association with hypothyroidism. The current case does also not serve to solve the question on the pathogenesis of this lesion.

Purpose: To investigate the clinical outcome of magnetic-resonance-guided focused ultrasound surgery (MRgFUS) treatment for symptomatic uterine fibroids in premenopausal women using the validated USF-QOL (Uterine Fibroid Symptom and Quality of Life) Questionnaire., Materials and Methods: 54 patients with symptomatic uterine fibroids were enrolled in this prospective study. The patients completed the UFS-QOL Questionnaire prior to MRgFUS treatment as well as after 3, 6, and 12 months., Results: The rate of technical success was 91.5 % (95.2 % after subtraction of screening errors). 6/54 patients (11 %) had other treatments (surgery, n = 4; UAE, n = 2), 8/54 (15 %) dropped out due to pregnancy, and 8/54 were lost to follow-up. The remaining group showed considerable symptom relief as early as after 3 months. The median overall quality of life score increased from 64.7 (quartile range QR: 49.8 - 77.6) before treatment to 77.6 (QR: 61.4 - 87.1) (p < 0.001), 78.4 (QR: 66.4 - 89.7) (p < 0.001), and 82.8 (QR: 69.8 - 92.2) (p < 0.001) at 3, 6, and 12 months, respectively. The corresponding median symptom severity score decreased from 46.9 (QR: 28.1 - 56.2) to 34.4 (QR: 21.9 - 43.7) at 3 months (p = 0.003) and 28.1 at 6 and 12 months (QR: 18.7 - 38.3, QR: 15.6 - 34.4) (p < 0.001, p = 0.002). The rate of complications requiring treatment was 9 %, and the rate of overall complications was 39 %. No major complications occurred., Conclusion: Our results indicate significant alleviation of fibroid-related symptoms within 12 months of MRgFUS with improvement beginning as early as 3 months after treatment. We observed no major complications, and some women became pregnant after MRgFUS. There was a low treatment failure rate of 11 %., (© Georg Thieme Verlag KG Stuttgart · New York.)

Leiomyomas are benign neoplasias consisting of smooth muscle tissue, with the most common localization being the uterus. Less often incidence is observed in other regions such as the blood vessels, esophagus and lower urinary tract. Leiomyomas occur only rarely in the head and neck area. We report about a female patient being treated because of progredient swelling and enlargement of the left parotid gland. The histological specimen revealed a regressive transformed tumor.

Malignant mesodermal tumors of the uterus are an inhomogenous group of uterine malignancies with different pathogenesis, clinical presentation and prognosis. These rare tumors represent approximately 1 % of all uterine malignancies. The aggressive carcinosarcomas or mixed muellerian tumors are defined by mixed malignant epithelial and malignant mesodermal histopathology and are of the same precursor cell origin like endometrial cancer. Thus, carcinosarcomas were reclassified by the FIGO as an aggressive type of endometrial cancer and treated like type II endometrial cancer. Adenosarcomas are also mixed tumors with benign epithelial proliferation and malignant mesodermal cell growth, have a good prognosis and represent less than 5 % of all mesodermal uterine malignancies. Besides carcinosarcomas, the pure mesodermal leiomyosarcomas are the most common mesodermal malignancies. Patients with leiomyosarcamos are usually perimenopausal, and although more than half of the patients present with symptoms, diagnosis occurs incidentally in most cases in final histopathologic workup of an excised putative myoma or uterus. Adequate anamnesis, gynecologic examination and careful imaging by transvaginal ultrasound in the preoperative setting might hint to correct differential diagnosis in many cases. Overall the prognosis of uterine leiomyomas is poor. Malignancies of the endometrial stroma are very rare and divided in two subgroups, the mostly estrogen receptor positive endometrial stromal sarcoma, which occur preferably in premenopausal women and show a favorable prognosis, and the very aggressive undifferentiated endometrial sarcomas. The more rare undifferentiated endometrial sarcomas occur in postmenopausal women and most patients die in the first two years after diagnosis. Risk stratification of preoperative differential diagnosis requires improvements and the correct histopathologic workup of mesodermal uterine malignancies is still a challenge for pathologists.

We report about a rare case of acute abdomen in a 43 years old female patient who noticed a sudden onset of severe lower abdominal pain, increasing in strength within a few hours. The transabdominal and transvaginal ultrasound showed an enlarged leiomyomatous uterus with a questionable torsion of a pedunculated subserous leiomyoma. The following magnetic resonance imaging confirms this diagnosis. During the laparoscopy a myomectomy has been performed.

Leiomyomas are benign neoplasms arising from smooth muscle cells. We describe the case of a 17-year-old boy admitted with progressive severe obstructive voiding symptoms. Retrograde urethrography showed a bulbous urethral stricture which was resected with primary urethral anastomosis. Histopathological examination confirmed the very rare case of a leiomyoma of the urethra. In patients with urethral stricture, leiomyoma should be included in the diagnostic considerations.

Myomas are the most frequent benign, solid tumours of the female genital tract in women of reproductive age. These tumours are estrogen dependent and their incidence rises with increasing age. A large number are asymptomatic, while others often cause bleeding disturbances or displacement complaints. Increasingly more women with uterus myomatosus desire to have children at a later age. In addition, progressively more women with myoma conditional complaints who have finished their family planning wish to retain their uterus. While the trend towards preserving organs has increased with the spread of minimal-invasive endoscopic techniques, minimal invasive radiological and non-invasive techniques are still searching for a place in the wide spectrum of treatment available today.

We report a patient with unexpected intraoperative diagnosis of a big leiomyoma of the distal esophagus found during laparoscopic repair of a typ III hiatal hernia complicated by Cameron ulcer and chronic anaemia. Laparoscopic transhiatal enucleation of the tumour was performed with closure of the myotomy, Nissen fundoplication, and crural repair. Briefly, the literature of leiomyoma of the esophagus is reviewed with special regard to different therapeutic strategies.

Background: Forgetting a foreign body in the abdominal cavity is an unpleasant and avoidable situation. It usually occurs when the preventive protocols are not followed precisely. In such a case clinical consequences are unpredictable and relaparotomy may become necessary., Case Presentation: We present the case of a temporary intestinal obstruction six months after a transabdominal hysterectomy. Diagnostic workup revealed a laparotomy-gauze left in the abdominal cavity at the previous operation. Exploration showed that the gauze was actually located in the intestinal lumen. The inflammatory reaction elicited by the foreign body eroded the intestinal wall and allowed its intraluminal migration. The gauze moved distally due to peristalsis until it became trapped in the ileocecal valve causing obstruction. When it finally passed through the valve the obstruction was relieved. Intraoperative maneuvers advanced the foreign body further forward until it was removed transanally., Conclusion: The formal processes - counting the gauzes continually and double crossing the counting - must be kept in every laparotomy to avoid the unpleasant experience of gauze remaining in the peritoneal cavity. In such an unfortunate case traditional open surgery provides a safe solution to the patient's problem.

Myoma-induced erythrocytosis is a rare clinical picture which is probably largely misunderstood. Pre- and postmenopausal women are affected. The characteristics of this syndrome are raised haemoglobin and haematocrit values, erythrocytosis at normal plasma volumes and the fact that these values are promptly and permanently corrected by myomectomy or hysterectomy. Myomatous erythrocytosis syndrome (MES) can be the explanation of normal haematological parameters in patients with myoma-related hypermenorrhoea and menorrhagia.

A five-year-old, neutered male, Bernese Mountain Dog was referred because of a two-week history of hematuria and a one-week history of polydipsia and polyuria. Palpation of the dorsomedial mesogastrium revealed a mass on the left side, which was seen via radiography and ultrasonography to be attached to the left kidney. The left kidney and the attached mass were excised surgically, and the dog had an uneventful recovery. Histological examination of the mass revealed a dense proliferation of non-polymorphic spindle cells, which stained positive for smooth muscle actin via immunohistochemistry. Leiomyoma of the kidney was diagnosed. Postoperatively, there was mild azotaemia, which did not affect the general condition of the dog and was still present 15 months after surgery. Leiomyoma of the kidney is a benign tumor, and hematuria may be the only clinical sign.

Leiomyomatosis peritonealis disseminata (LPD) is a rare disease, which is most often found in women in reproductive age - seldom pre- and postmenaupausal. LPD has been described in women taking oral contraceptives or during pregnancy. LPD is mostly asymptomatic and discovered during operations like section caesarea, etc. Because of the macroscopic aspect (multiple small nodules <2 cm) a metastasing tumour is suspected during operation. These nodules consist of smooth muscle fibres and show benign histologic features. An increased level of cases with similar endometriosis (10%), myoms of uterus or functional ovarian tumours have been reported. Few cases of malignant transformation have also been described. In the pathogenesis of LPD a metaplastic change of submesothelial multipotential mesenchymal cells as an abnormal response on hormonal stimulation is debated. A regression of LPD after delivery or after stopping oral contraceptives is possible. Another therapeutic option is the application of GnRH-agonists. We present a case of a 35-year old female patient with sudden abdominal pain and suspicious findings in abominal ultrasound and CT-abdomen. The intraoperative aspect shows diffuse intraabdominal nodules consisting of smooth muscle fibres and a cystic left ovary. LPD, endometriosis and a borderline lesion of the left ovary were diagnosed by intraoperative histological examination. A bilateral salpingo-oophorectomy and omentectomy were performed.

In Gynaecology there have been many innovative developments towards minimal invasive surgery. Today patients can profit of these new techniques in all fields of gynaecological surgery, some of which are described: The treatment of benign adnexal pathology including ectopic pregnancy is a domain of laparoscopy. Also symptomatic myomas can be enucleated by laparoscopy with favourable pregnancy outcome. The role of endoscopy in malignant disease has still to be defined though pelvic and paraaortal lymphonodectomy and even radical hysterectomy have been shown to be feasible. Pathology of the uterine cavity (myomas, polyps, septae) is routinely treated by hysteroscopy. The concept of operative treatment of stress urinary incontinence has changed since the minimal invasive TVT procedure has shown to be as successful as the classic colposuspension. For patients with breast cancer there has been a change from (ultra-) radical surgery to breast conserving treatment. Furthermore with the concept of the sentinel lymphnode a reduction of the morbidity of the classical lymphonodectomy is achieved without loss of information about the axillary lymphnode status.

Introduction: Leiomyoma of the urinary bladder is a rare, benign tumor of mesenchymal origin. Treatment options are discussed. Besides open surgery and transurethral resection of small, submucosal tumors, laparoscopic excision is an effective therapeutical option with a low complication rate., Case Report: We report the medical history of a 36-year-old woman suffering from a leiomyoma of the urinary bladder and the therapy through laparoscopic excision., Conclusions: Laparoscopic removal of urinary bladder leiomyomas is a suitable alternative to common therapeutical procedures.

Medical History: A 38-yr-old woman suffered from excessive blood loss after elective removal of the uterus because of a leiomyoma. The surgical attempt to stop the bleeding failed. The laboratory evaluation before surgery showed normal coagulation parameters (aPTT 23.4 sec, TPZ > 100 %, platelet count 267 000/microl)., Development: Despite treatment with the plasminogen activator inhibitor Tranexamic Acid (2 x 500 mg) and 10 units of concentrated platelets as well as 31 units of fresh frozen plasma and 31 units of red blood cell concentrates the bleeding continued. Reaching an cumulative blood loss of 15 000 ml the patient developed ventricular fibrillation necessitating cardiac resuscitation including defibrillation and application of epinephrine 7 mg. At this point systolic blood pressure decreased from 90 to 70 mm Hg, the core temperature was 31,9 degrees C. After successful resuscitation (systolic blood-pressure 90 mm Hg after 15 min) the bleeding started again with a blood loss of 2000 ml requiring 3 units of fresh frozen plasma and 3 red cell concentrates Use of recombinant activated Factor VII (r.FVIIa): 6 mg (300 KiU) r.FVIIa have been applied (92 microg/kgKG [4.6 KiE/kg]). Within 10 minutes the bleeding stopped. More transfusions were not necessary. The patient left the intensive care unit 8 days after the operation without neurological deficit., Conclusion: The use of recombinant Factor VIIa may stop excessive haemorrhage, even if the cause is unknown.

We report a case of postoperative ileocecal invagination in a 63-year-old male. Forty-six days after esophageal resection and gastric tube reconstruction with cervical anastomosis for an esophageal carcinoma, the patient suffered from colicky pain in the right abdomen. The diagnostics showed an ileocecal invagination up to the right flexure of the colon. The invagination was based on a leiomyoma of the terminal ileum. Because of necrosis of the mucous membrane, an ileocecal resection with ileoascendostomy could not be avoided. We discuss this case on the basis of the existing literature.

Uterine fibroids are the most common benign tumour affecting the female reproductive tract, 20% of all women older than 35 years are afflicted. Patients with fibroids tend to be asymptomatic, but fibroids may lead to meno-, metrorrhagia, hyper- and dysmenorrhoea and urination and defecation problems. If the fibroids do not cause any clinical symptoms and if there is no suspicion of a malignant tumor, there is no need for therapeutic intervention. Otherwise, besides the medical management with gestagenes and GnRH (gonadotropin-releasing hormone) analog, surgery represents the classical treatment. Hysterectomy is the common approach for women with completed family planning. For women who wish to conserve their fertility enucleation of the fibroids can be considered. These surgical procedures can be performed endoscopically or abdominally. Uterine artery embolisation, a radiological intervention, is less invasive and represents an interesting therapeutic alternative.

Background: To evaluate the current situation and implementation of embolization of uterine leiomyomas into the treatment concept in women with symptomatic uterine leiomyomas in Germany., Material and Methods: A questionnaire addressing the clinical background of uterine myomas, recommended treatment concepts, preclinical evaluation, technical approach and complications was sent to 164 departments of gynecology and radiology in Germany., Results: 33 radiological departments and 19 gynecological departments submitted a completed questionnaire. Only 7 departments of radiology reported to have own experience with embolization of uterine leiomyomas, while only 2 departments of gynecology considered embolization as an alternative treatment option in patients with symptomatic leiomyomas. 18/33 radiological departments offer this treatment option but get no patient referrals. Agreement was found concerning the indications for treatment, preclinical evaluation by ultrasound and MRI, preferable location of treatable fibroids, technical approach and pain management., Conclusion: The embolization of uterine leiomyomas in patients with symptomatic myomas is regardless of the well documented high efficacy and low complication rate not yet an established treatment option in Germany. Interventional radiologists and gynecologists have to evaluate the indications for the embolization of uterine leiomyomas together before the procedure is advised to the patient, because it seems mandatory to add this procedure to the standard armamentarium of treatment options in uterine myomas.

Aim: Our goal was to evaluate risks and complication rate of uterine fibroid embolization (UFE)., Results: The most frequent complications reported in the literature are associated with angiography procedure, serious complications are extremely infrequent., Conclusion: The embolization of fibroids is a safe angiographic intervention. Nevertheless, the interventional radiologist must be aware of the common risks and complication and the strategies to avoid them.

Introduction: With the increased use of endoscopic techniques, the rare, benign submucosal gastric tumors are being detected more frequently. We report our results with a combined laparoscopic-endoscopic approach for minimally invasive resection of these tumors., Method: The intraoperative endoscopy allows precise localization of the lesion by direct visualization and diaphanoscopy. Extragastral wedge resection of the stomach using the lifting method was carried out in patient with tumors of the anterior wall, lesser curvature and greater curvature. In tumors of the posterior wall, near the cardia or pylorus we performed an intragastric resection. One trocar with a balloon was inserted into the stomach. This trocar was used to introduce the endostapler into the stomach., Results: We performed this combined laparoscopic-endoscopic resection in 9 patients (5 extragastral; 4 intragastral). The tumor size of intragastral resection was 34 +/- 5 mm (range 28 to 41 mm) and 36 +/- 7 mm (range 26 to 47 mm) in intragastral resections. The histological examination revealed 7 gastric stromal tumors and 2 leiomyomas. There were no intra- or postoperative complications. The oral nutrition started on p.o. day 2. Hospital stay ranged from 4 to 8 days (6.4 days)., Conclusion: The minimally invasive combined laparoscopic-endoscopic resection of benign gastric wall tumors is a safe procedure with a low mortality and morbidity. The tumor localisation is the main criterion for decision on an extra- or intragastral approach.

Leiomyomas are benign tumors that can arise in the smooth muscle and can appear practically everywhere; hence, they must be taken into consideration as a rare possibility in the differential diagnosis of numerous tumors. While leiomyomas of the peripheral vessels are a relatively common finding, they are rarely found in the central vessels. Only a few cases of leiomyomas in the vena cava are known. In contrast to malignant leiomyosarcomas, leiomyomas usually grow towards the lumen. We report on the rare case of a leiomyoma in the inferior vena cava that appeared in the image to be located in the adrenal gland. Therefore, transperitoneal extirpation of the site was undertaken. It was only during surgery that a tumor emanating from the vessel wall became apparent. Thus, after an initial laparoscopic approach it became necessary to change to open resection of the tumor with cavotomy and resection of the vessel wall. The histopathological work-up revealed a benign leiomyoma and further imaging diagnostics gave no indication for the presence of metastases.

Dysfunction of the median nerve is quite common and mostly observed related to carpal tunnel and pronator syndromes. We report a rare case of median nerve compression caused by a leiomyoma in the distal forearm. Spiral CT with MPR (multiplanar reconstruction) clearly located the lesion preoperatively.

A 101-year-old patient presented with uterine myomatosis and bleeding associated with a large hematometra. An abdominal hysterectomy with adnexectomy was performed following an in-depth consultation with the patient and her daughter. The patient was discharged on the 12(th) postoperative day after a complication-free course. This case report demonstrates not only the current possibilities in the gynecological treatment of very old patients but also the hidden reserves in the gynecological care ot these women.

Renal leiomyoma is a rare benign tumor which has its origin in smooth muscle cells of different structures of the kidney. The clinical incidence of renal leiomyoma is much lower than the frequency described in large autopsy studies. Renal leiomyomas are mainly located in the renal capsula and pelvis or next to those structures. Clinical symptoms are nonspecific (e.g., flank pain or flank tumor) or completely absent, making most of the leiomyomas an incidental finding during routine diagnostics. A differential diagnosis between renal leiomyoma and renal cell carcinoma on the basis of medical imaging is extremely difficult. Therefore, laparotomy and nephrectomy are performed in most cases of suspected renal cell carcinoma. The definitive diagnosis of a leiomyoma is only possible after histological examination of the tumor. Due to the rising number of diagnoses resulting from improved medical imaging, renal leiomyomas are gaining more importance in the differential diagnosis of renal cell carcinoma, especially with respect to kidney-sparing surgery.

Background: Leiomyoma and Leiomyosarkoma are not often found in ENT-diseases., Patients: We report on a 62-year old female patient presenting with a 3 x 4 cm tumor in the oropharynx that had developed within a period of about three weeks. The patient complained of increasing dysphagia and dyspnea especially when lying on the left side. To secure breathing the patient had to be primarily ventilated by placing a needle percutaneously through the conical ligament and was then intubated. For this procedure the patient was positioned on the right side. The tumor measuring 3 cm, was removed surgically., Results: The tumor turned out to be a leiomyomatous neoplasia of undetermined malignant potential. Since an unfavourable behaviour of such neoplasms cannot be excluded, patients with tumors of this type should be followed closely., Conclusions: In this case the tumor leads to an acute dyspnoea and a special procedure of anesthesia was necessary. Therapeutic considerations and differential diagnosis of this very rare tumor of the oropharynx are discussed by reviewing the literature.

History and Admission Findings: A 45-year-old woman was refferred for diagnosis of an accidentally found symptomless space-occupying lesions in the central part of the right lung. She had undergone a hysterectomy 4 years before and reported smoking 15 cigarettes daily since the age of 17 years. Physical examination was normal., Investigations: As primary bronchial carcinoma or metastasis to the lung was suspected she underwent a series of diagnostic tests: sonography, computed tomography (CT), gastroscopy, coloscopy, bronchoscopy, skeletal scintigraphy, gynaecological examination and various laboratory tests, none of which indicated a primary extrapulmonary tumour. CT-guided fine-needle biopsy then suggested benign metastasizing pulmonary leiomyoma (BMPL)., Treatment and Course: The largest of the tumours were surgically removed, confirming BMPL. Hormone receptors (for oestrogen, progesterone) having been demonstrated, progesterone treatment was initiated as prophylaxis against recurrences. CT 6 months later revealed new intrapulmonary foci. Administration of luteinizing hormone-releasing hormone analog to stop completely any oestrogen effect, and CT of the thorax 6 months later showed that both tumour numbers and their size had been reduced. The patient remained asymptomatic and the findings had not changed in the subsequent 12 months., Conclusion: BMPL is a rare cause of a space-occupying pulmonary lesion, predominantly affecting middle-aged women after hysterectomy for uterine myoma. The pathogenesis remains unclear, hormone-dependent tumour growth being discussed as a possible mechanism. Anti-oestrogen administration is the treatment of choice to achieve remission and effective prevention of recurrences.

Pulmonary nodules resected in 10 patients were histologically classified as benign metastatic leiomyoma of the uterus. Hysterectomy because of myoma had been performed between 0 and 24 years earlier (median 14.9 years). Between 1 and 27 nodules were found in one or both lungs. Patients presenting with a single nodule had it resected with diagnostic intent and were followed up. Multiple nodules were resected if the loss of parenchyma was tolerable; otherwise, one lesion was resected for diagnosis. In some cases antihormonal therapy was performed postoperatively. The median duration of follow-up was 4.7 years. In this time, no local complication occurred, and no patient died of this disease. Apparently, benign metastatic leiomyoma of the uterus biologically shows benign behaviour. New manifestation or progressing growth of non-resected lesions does occur, however. Consequently, regular follow-up is required. Local complications indicate surgical intervention.

Aim: To give recommendations for the standard diagnostic assessment of urethral diverticula and periurethral masses based on an evaluation of our results and a survey of the recent literature., Methods: Group I (1981-1993) included 47 women in whom urethral diverticula (n = 34), periurethral cysts (n = 11), and periurethral leiomyomas (n = 2) were diagnosed and the results compared with the intraoperative findings. Diagnostic work-up comprised history taking, vaginal palpation, introitus ultrasound, double-balloon urethrography (DBU), voiding cystourethroscopy (VCU), excretion urography (EU), and urethrocystoscopy. Group II (1994-1996) included 12 women with urethral diverticula who were examined by DBU, 2D and 3D introitus ultrasound. The diagnostic accuracy of the different methods was assessed., Results: Group I: The diagnostic accuracy in identifying urethral diverticula was 85.3% for palpation, 61.5% for introitus ultrasound, 93.8% for DBU, 37.5% for EU, and 30.0% for urethrocystoscopy. Of all imaging modalities used, only introitus ultrasound depicted periurethral cysts and leiomyomas. Group II: The DBU, 2D and 3D introitus ultrasound had a diagnostic accuracy of 100% in identifying urethral diverticula., Conclusions: Introitus ultrasound should be used as the basic diagnostic tool in clinically suspected urethral diverticula or periurethral masses and additional DBU should be restricted to cases with inconclusive findings.

Background: Spontaneous enophthalmos without recent trauma is a rare condition. Its origin is difficult to evaluate., Method: Specific properties of this symptom complex are presented based on a literature review and on case reports. Possible connections between enophthalmos and paranasal sinus diseases as well as differential diagnoses are analysed., Patients: 1. 31 year old female patient with right spontaneous enophthalmos and no history of trauma. CT-imaging disclosed tissue formation in the maxillary sinus, partially destroyed medial orbital wall and floor, descended orbital contents following Caldwell-Luc procedure several years previously. After endonasal surgery of ethmoidal and maxillary sinus with removal of a large cyst good functional and cosmetical result. 2. 25 year old male patient complaining of pain in the periorbital region, presenting with left enophthalmos and superonasal deviation of the eyeball. MRI and CT revealed a tumor in the orbital floor region with total destruction of the roof of the maxillary sinus. Removal of the tumor by a combined lateral rhinotomy and subciliary approach., Diagnosis: Leiomyoma. Orbital reconstruction with PDS-sheet. Postoperatively, improved globe position and motility. No recurrence during three year follow-up., Conclusion: When evaluating the causes of enophthalmos, chronic diseases of the paranasal sinuses or their walls must be considered. Surgical therapy is promising.

Myoma is one of the most common benign diseases of the female genital tract. The surgical management of this entity has been altered over the last years from complete hysterectomy to conservative enucleation of the myomas. We retrospectively compared our data concerning laparoscopic or open myomectomies. Over a period of 2 years, we operated 207 myomas in 102 patients. Of this collective, 69 (67.6%) were operated on laparoscopically and 33 (32.4%) via an open approach. In both groups, the median number of myomas was 2 (1-7). The mean diameter of the largest myoma was 5.1 +/- 2.4 cm (laparoscopy) and 6.2 +/- 2.6 cm (laparotomy), respectively. The additive diameter of myomas was 7.7 +/- 5.1 cm (laparoscopy) and 9.8 +/- 4.1 cm (laparotomy), respectively. There was no relevant difference between the groups in terms of operating time and blood loss. Four (3.9%) laparoscopies had to be converted to an open approach. In three cases (2.9%) a laparoscopically assisted enucleation had to be performed, requiring a mini-laparotomy 4 to 5 cm in length. We encountered no severe complications. Given appropriate indication, laparoscopic myomectomy is an easy-to-perform and minimally invasive technique with a low complication rate.

Glans penis leiomyomas are uncommon as primary nonepithelial tumors of the urogenital tract. Only 4 cases are described until today. We saw an other case of an 12 years old boy with a leiomyoma of the glans penis. Clinically the lesion presented as a yellow induration with no symptoms as pain, pruritus or bleeding. The biopsy revealed histological a leiomyoma in the subcutis of the glans penis with no symptoms of malignancy. Because of suspected functional and cosmetic deficiency a total resection was not performed. None of the cases described in the literature showed in the follow up malignancy or recurrency. 18 months postoperatively our patient is furthermore well and without symptoms. Nevertheless the leiomyoma of that localization is rare, this tumor should be included in the differential diagnosis of the neoplasms of the glans penis.

In contrast to children, intussusception is an unusual cause of an abdominal emergency in adults. We report on a 65-year-old patient who complained of inconstant crampy abdominal pain for a period of over 6 months. He was admitted to our hospital because of acute intestinal obstruction. Sonography and computer tomography suggested an intussusception. At surgery the diagnosis of an ileo-ileal invagination was confirmed and resection of a segment of the ileum was performed. As shown by macroscopic findings intussusception had existed for several days. Histologically, the underlying disease causing the intussusception was a leiomyoma arising from the submucosa.

A 74-years old patient is admitted to the hospital with a over a period of 4 years growing, scrotal, ulcerated tumor. There is no connection to the testicle or the epididymis palpable. All laboratory findings including the tumorparameters are normal. The scrotal sonography shows a solid tumor, that is filled with vessels in the Doppler sonography. The complete tumor resection with histological examination leads to the diagnosis of a scrotal leiomyoma. This rare, benign tumor is a differential diagnosis to paratesticular or non-germinal tumors.

We report the rare combination of a monoamniotic twin pregnancy with giant uterine leiomyomas in a 33-year-old para 0, gravida 1. Considering the restricted capacity of uterine expansion during pregnancy and the known complications associated with myomas, as well as the elevated morbidity and mortality of monoamniotic twin pregnancies, we opted for a medically indicated abortion at 12 weeks' gestation. After abortion the patient developed fever and abdominal pain. In differential diagnosis we considered endomyometritis and necrosis of the myomas. Despite adequate conservative treatment the symptoms persisted and myomectomy was performed in view of the patient's desire to maintain fertility.

Retrospectively analyzing the history of three patients with gastrointestinal stromal tumors (GIST) treated over a period of 1 year in the surgical department of our regional hospital, we tried to answer the following questions: using the current recommendations in the literature, how are the macro- and microscopic features and clinical presentation to be interpreted? Which prognostic and therapeutic conclusions should we draw, giving special consideration to practice-orientated management of such cases. The patients were 65, 75 and 88 years old respectively, and in each case the GIST manifested as recurrent gastrointestinal bleeding. During surgical treatment four gastric tumors ranging in cross section between 2.5 and 8 cm were found. The GIST diagnosis was established after light microscopic and immunohistochemical examinations. Going through the current literature, a large number of structural and immunohistochemical criteria have come to light for determining its classification and potential malignancy. On the other hand, very few subsequent recommendations concerning therapy and prognosis can be found and follow-up recommendations are almost unavailable. We conclude that GISTs are difficult to diagnose because of their locality and that their clinical behavior is uncertain. The potential malignancy, on the other hand, requires a well-founded diagnostic procedure in the form of the best possible pre-therapeutic staging. Furthermore, initially radical surgical treatment should be adopted and the follow-up should be adapted to the risk involved. The latter is arbitrary and further clinical studies are required.

History and Admission Findings: Because of tarry stools a 64-year-old woman had two years previously undergone oesophagogastroduodenoscopy (OGD), coloscopy and examination of the small intestine (according to Sellink) without significant findings. She was again hospitalized because of anemia (6.1 g/dl). Physical examination was unremarkable., Investigations: After unremarkable OGD (as far as the descending part of the duodenum) and coloscopy, hypotonic duodenography revealed a tumor in the region of the duodenojejunal flexure., Treatment and Course: The tumor, histologically a leiomyoma, was resected., Conclusion: OGD, coloscopy and small intestinal radiography may fall to identify the source of bleeding because of a diagnostic gap in the region of the duodenojejunal flexure. In this case hypotonic duodenography should be performed, if enteroscopy is not available.

Objective: How to prevent severe complications of lower leg compartment syndrome following gynecologic operations in the lithotomy position?, Material and Methods: Two cases of lower leg compartment syndrome following long lasting gynecologic operations are presented., Results: Early diagnosis by clinical signs, measurement of compartment pressure and creatine kinase activity and undelayed surgical intervention can avoid acute renal failure due to rhabdomyolysis and damage of neuromuscular function., Conclusions: Early diagnosis and undelayed surgical intervention can prevent severe complications of lower leg compartment syndrome following gynecologic operations in the lithotomy position.