Endometriose de cicatriz cirúrgica: estudo retrospectivo de 72 casos

Abstract

Artigos originaisResumo OBJETIVO: avaliar a freqüência e fatores associados à endometriose de cicatriz cirúrgica. MÉTODOS: foi realizado estudo observacional, tipo coorte retrospectivo, a partir da revisão de prontuários de pacientes do Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG) com diagnóstico anatomopatológico de endometriose de cicatriz cirúrgica, no período de maio de 1978 a dezembro de 2003. RESULTADOS: foram encontrados 72 pacientes com diagnóstico de endometriose de cicatriz. A incidência de endometriose de cicatriz após cesariana foi signifi cativamente maior do que após parto normal (0,2 e 0,06%, respectivamente; p<0,00001), com um risco relativo de 3,3. A idade das mulheres, no momento do diagnóstico, variou de 16 a 48 anos, com média de 30,8 anos. A localização da lesão variou conforme a cirurgia prévia: 46 cesarianas, uma histerectomia e uma abdominoplastia (48 lesões na parede abdominal); 19 partos normais com episiotomias, uma recidiva e duas perineoplastias (22 lesões perineais); duas mulheres sem história de cirurgia ginecológica prévia (uma lesão na cicatriz umbilical e uma na parede vaginal posterior). A dor foi o sintoma mais freqüente (80%), seguido de nódulo (79%), e, em mais de 40%, a dor e o nódulo sofreram modifi cações com o período menstrual. Outras queixas menos freqüentes foram: dispareunia, infertilidade secundária, dor pélvica, dismenorréia, secreção na cicatriz, menorragia e dor à evacuação. O intervalo de tempo médio entre a cirurgia e o início dos sintomas foi de 3,7 anos. O tamanho médio da lesão foi de 3,07 cm. A hipótese diagnóstica, baseada na avaliação clínica, foi correta em 71% dos casos. O tratamento de escolha em todos os casos foi a exérese cirúrgica. Em apenas uma ocorrência houve recidiva e nova intervenção. CONCLUSÕES: a endometriose de cicatriz cirúrgica é situação rara, originada, na maioria das vezes, a partir de procedimento cirúrgico obstétrico, com maior risco após parto abdominal. Apresenta quadro clínico altamente sugestivo, sendo raramente necessário exame complementar.Abstract PURPOSE: to identify the incidence and associated factors of surgical scar endometriosis. METHODS: a retrospective cohort observational study performed from the medical records of female patients attended at the Clinical Hospital of Univesidade Federal de Minas Gerais (UFMG) with histopathological diagnosis of scar endometriosis from May 1978 to December 2003. RESULTS: a total of 72 patients were included in the study. The incidence of scar endometriosis after cesarean section was signifi cantly higher than after episiotomy (0.2% and 0.06%, respectively; p<0.00001) with relative risk of 3.3. The women's age, when diagnosed, ranged from 16 to 48 years old, (mean=30.8 years old). The scar location varied according to the previous surgery: 46 scars after cesarean sections, one after hysterectomy and one after abdominal surgery (48 lesions in the abdominal wall); 19 scars after episiotomy, one because of relapse and two after pelvic fl oor surgeries (22 pelvic wo...

Scar endometrioma following obstetric surgical incisions: retrospective study on 33 cases and review of the literature

“…6 The current study evaluated the frequency of scar endometrioma over a six-year period, with 33 cases, which is a proportionally representative number and, when compared with larger studies in terms of absolute numbers, it is highly relevant. 6,[16][17][18][19][20] Furthermore, all the cases described in the present study underwent surgery performed by the same team, which means that the team acquired great experience in handling this disease. Even though there have recently been studies presenting larger numbers of cases, better understanding should be reached through profiling the disease, searching for more efficient actions for prevention, diagnosis and therapeutics, and publishing such information in the medical media.…”

“…The few studies that have described the incidence of endometriosis following delivery evaluated it in their services in the same way. 2,6,10,17,21 A small number of studies have estimated the incidence of scar endometrioma following vaginal delivery alone. 6 The rate relating to vaginal delivery in the present study was much lower (0.01%) than what had previously been reported, which had ranged from 0.06 to 0.7%.…”

“…2,6,10,17,21 A small number of studies have estimated the incidence of scar endometrioma following vaginal delivery alone. 6 The rate relating to vaginal delivery in the present study was much lower (0.01%) than what had previously been reported, which had ranged from 0.06 to 0.7%. However, methodological factors compromised this specific incidence, probably because of lack of patient follow-up over the years after the delivery or different techniques used in general hospitals and maternity hospitals for performing episiotomies.…”

“…4,5 However, most of the cases reported have occurred following obstetric procedures that exposed the endometrial tissue, especially in cases of cesarean section. [6][7][8] The term scar endometrioma is used for well-marked tumoral lesions, such as non-neoplastic granuloma or tumor. It is formed by whitish fibrous tissue, with thick chocolate-like colored liquid areas, and is located anywhere in the surgical scar 7 ( Figure 1).…”

“…[8][9][10] Its frequency in episiotomy scars is much smaller than in abdominal wall scars. 6 The theory of iatrogenic implantation is the one most accepted by several authors, and other theories are secondary to this, in order to explain the physiopathology. 11,12 Certain factors relating the knowledge of the clinical background of the disease make correct diagnosis difficult, especially among general surgeons, who most commonly make mistakes during diagnosis.…”