Disseminated peritoneal leiomyomatosis with multiple recurrences of uterine fibroids after laparoscopic myomectomy: a case report

Disseminated peritoneal leiomyomatosis (DPL), also known as leiomyomatosis peritonealis disseminata (LPD), may be a rare but clinically important iatrogenic complication after laparoscopic myomectomy, especially associated with the use of electric power morcellators. During morcellation, tiny tissue fragments may disseminate into the abdominal cavity, implant ectopically, and grow into peritoneal leiomyomas. However, DPL has an insidious onset and lacks specific clinical manifestations; diagnosis is often delayed and management may be inappropriate. A 47-year-old woman underwent three uterine fibroid-related surgeries within 10 years. The first was laparoscopic myomectomy approximately 10 years earlier, during which an electric power morcellator was used. Five years later, open myomectomy was performed for recurrence, and no peritoneal implants were observed. She also had a history of cesarean section with concurrent right ovarian cyst surgery in 2002; the exact procedure could not be confirmed from the available records, but the right ovary and tube were absent at the 2022 operation. At this admission, the patient presented with increased menstrual flow and progressively worsening dysmenorrhea. Intraoperative exploration revealed approximately 15 implant nodules scattered on the pelvic peritoneum, vesicouterine fold, rectouterine pouch, small bowel serosa, and omentum. Pathological examination was consistent with DPL (SMA+, desmin+, h-caldesmon+, mitotic count <1/10 HPF, Ki-67 hotspot area approximately 5%).Immunohistochemistry was performed on the peritoneal implant nodules. No coagulative tumor cell necrosis was identified; cytologic atypia was absent to mild. This case suggests that iatrogenic peritoneal dissemination may remain occult for a long time, and the interval from morcellator use to macroscopically visible peritoneal implants can exceed 10 years. Routine use of a specimen retrieval bag during morcellation is recommended; systematic peritoneal exploration is suggested at reoperation in patients with a history of morcellator use; and for perimenopausal patients without fertility requirements, with severe symptoms and extensive lesions,total hysterectomy plus left adnexectomy, because the right adnexa were already absent, may be considered to reduce the risk of recurrence, but decisions should be individualized.