Page 287 - Read Online

Page 2 of 8 Goh et al. Mini-invasive Surg 2021;5:30 https://dx.doi.org/10.20517/2574-1225.2021.42

However, it is known that incidence of cancer is higher in transplant recipients than in patients undergoing
dialysis for ESRD. It has been hypothesised that this could be attributed to the immunosuppressants regime
[4]
transplant recipients received .

This case report describes three cases of gynaecologic pathologies in kidney transplant recipients and the
use of laparo-endoscopic single site surgery (LESS) to perform a total hysterectomy and bilateral salpingo-
[5]
oophorectomy (THBSO). In our literature review, only Zhang and Li previously described the use of LESS
for THBSO in kidney transplant recipients, but there was minimal information on the type of instruments
used and the management of these patients perioperatively. Therefore, to our best knowledge, performing
LESS using homemade gloves and conventional laparoscopic instruments in renal transplant recipients has
never been described before.

CASE REPORT
Case # 1
A 61-year-old female with a body mass index (BMI) of 22.5, who had one child delivered through normal
vaginal delivery, presented with significant post-menopausal bleeding of one week duration requiring
admission and blood transfusion in view of her low haemoglobin count which dropped from 12.0 to
7.7 g/dL. She has a significant past medical history of hypertension, hyperlipidaemia, ESRD secondary to
hypertensive nephrosclerosis, mitral regurgitation and atrial fibrillation. She eventually had a deceased
donor renal transplantation to the right iliac fossa [Figure 1A]. Her immunosuppressants were 5 mg oral
prednisolone and 100 mg oral ciclosporin. She was not initiated on anti-coagulants for her recently
diagnosed atrial fibrillation in view of her upcoming gynaecological surgery.

On her abdomen, there was a suprapubic transverse scar extending to the right iliac fossa. The right
transplanted kidney was palpable over the right iliac fossa. On speculum, vagina and bimanual examination,
the cervix appeared normal, and no obvious mass was felt.

A pelvic ultrasound was performed, which revealed a thickened endometrium of 5.7 mm, a 25 mm × 17 mm
× 23 mm unilocular mass in the right adnexal region with no fluid in the Pouch of Douglas and no other
masses seen in the pelvis. The IOTA score was 20%. Subsequently, histological features obtained from an
endometrial biopsy suggested anovulatory cycles with disordered proliferation. At the same time, a pelvic
MRI [Figure 1B] was ordered, but the malignant potential of the ovarian mass was still uncertain. Her
CA125 level was 57.9. Her Papanicolaou smear yielded no abnormal finding. In view of the significant post-
menopausal bleeding in the presence of a right adnexal mass, our impression was an ovarian hormone
secreting tumour. Treatment options were discussed with the patient; she was keen for surgery and
counselled for LESS THBSO and omental biopsy.

During the surgery, a homemade single-port system comprising of the Alexis® wound retractor (Applied
Medical, CA, USA) and a 7½ surgical glove was used. After making a 2.5 cm umbilical skin incision, the
wound retractor was inserted into the peritoneal cavity through the umbilicus, and the glove was fixed to
the outer ring of the wound retractor. Upon making small incisions in the fingertip portions of the glove,
two 5-mm trocars and one 12-mm trocar were inserted. A rigid 30°, 5 mm diameter, 45 cm long endoscope
was used. The transplanted kidney was visualised at the right iliac fossa. A diagnostic laparoscopy
established slightly enlarged bilateral ovarian masses without any evidence of ovarian malignancy. The right
ovary measured 3.2 cm × 2 cm × 1.6 cm, while the left ovary was 4 cm × 1.5 cm × 1.5 cm. Overall, the
procedure was uneventful with minimal blood loss. The final histopathological diagnosis for the patient
turned out to be disordered proliferative endometrium and bilateral ovarian Sertoli-Leydig cell tumour