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

Figure 3. CT Pelvis Axial View showing the left adnexal mass and the transplanted kidney in the right iliac fossa (A). PAbdomen showing
suprapubic transverse scar extending to the right iliac fossa (B).

On examination, there was a suprapubic transverse scar extending to the right iliac fossa [Figure 3B]. The
right transplanted kidney was palpable over the right iliac fossa. The cervix appeared normal, and no
obvious mass was felt on bimanual examination.

Pelvic ultrasound revealed a 6.0 cm × 5.0 cm × 3.5 cm multiloculated cystic mass in the left adnexal region.
Colour Doppler showed mild vascularity within the mass. No ascites or other masses were noted. Tumour
markers CA125 and CEA were raised to 71.8 and 11.6, respectively. The IOTA and RMI score were 6.8%
and 646, respectively, suggesting a high risk of malignancy.

In view of the risk of malignancy and her immunosuppressed state, LESS THBSO was advised, and the
patient was keen for the surgery.

Preoperatively, warfarin and dipyridamole were stopped 5 and 2 days prior to surgery, respectively. PT was
10.5, aPTT was 28.2 and INR was 1.0. Her preoperative Hb was 11.2. The surgical technique was similar to
the first case as described above. The procedure was uneventful and there was minimal bleeding (20 mL).
The final histology reported a left ovarian mucinous cystadenoma.

Postoperatively, the patient recovered well and was started on clexane by the haematologist. She was
discharged on Postoperative Day 3. Currently, she is on follow-up with the gynaecological oncologist.

DISCUSSION
Performing a hysterectomy with bilateral salpingo-oophorectomy on a renal transplant recipient is not
without its challenge. In a paper written by Heisler regarding hysterectomy in women who have undergone
renal transplantation, it is reported that 41.4% (n = 58) of these patients experience postoperative
complications, the most common being wound infection and bleeding requiring blood transfusion. Such
complications were seen mainly in open hysterectomy . This was much higher in comparison to healthy
[6]
women, in whom the figures are at an estimated 3%-22%. In the following paragraphs, we elaborate on the
unique challenges faced during the operative care of kidney transplant recipients.

Bleeding requiring blood transfusion was reported as a common complication of hysterectomy in renal
transplant recipients. This was because open hysterectomy was performed and many of these patients were
on antithrombotic therapy . In our first and second cases, the patients were not on these medications. In
[6]