Surgical Management of Disseminated Peritoneal Leiomyomatosis

INTRODUCTION: Disseminated peritoneal leiomyomatosis (DPL) is characterized by widespread intra-abdominal, pelvic, or retroperitoneal benign, smooth muscle masses. Although benign in most cases, it has the potential for malignant transformation. It is most often attributed to iatrogenic tumor cell spread during uncontained morcellation. DPL can be difficult to diagnose preoperatively given the atypical location of masses and often ambiguous patient presentation. Initial workup should include a thorough history and physical exam and imaging OBJECTIVE: The objective of this video is to describe a case of disseminated peritoneal leiomyomatosis and discuss the preoperative workup, management, and postoperative considerations. We will also illustrate surgical techniques to optimize resection. METHODS: The patient is a 48-year-old female with a history of total laparoscopic hysterectomy with morcellation for symptomatic uterine fibroids. The patient presented to clinic 10 years after her initial procedure with chronic, cyclical pelvic pain, associated with urinary urgency and tenesmus. She was started on progestin therapy in the setting of a high clinical suspicion for endometriosis, with initial symptomatic improvement, but opted for surgical management given the persistence of pain. Given the presence of bowel and bladder symptoms, MRI was obtained for preoperative planning. RESULTS: Imaging revealed findings suspicious for deep endometriosis, including nodular thickening of bilateral round ligament remnants, a nodule with spiculated fibrotic tethering and hemorrhagic foci, involving the right ovary and terminal ileum, as well as a smooth, lobulated structure abutting both the bladder and vaginal cuff, with fibrotic tethering extending to the right adnexa. It also revealed a nodule suspicious for deep infiltrative endometriosis in the proximal umbilicus. Laparoscopy revealed suspected disseminated leiomyomas at the umbilicus, vaginal cuff, and bilateral round ligament remnants. A sponge-stick and EEA sizer were used to delineate anatomical borders, and cystoscopy with injection of reconstituted indocyanine green (ICG) through ureteral catheters was performed for identification of the ureters. The leiomyomas were carefully dissected and fully excised to prevent recurrence. CONCLUSIONS: DPL can prove to be a challenging diagnosis, given the rarity and variability of patient symptoms. Preoperative imaging, although often ambiguous, can be utilized to help guide surgical planning. Differential diagnosis typically includes disseminated malignancy, or more rarely, deep endometriosis as presumed initially in this case. Excision of DPL can help manage patient symptoms, and risk of recurrence is low if complete resection is achieved.