Design: Retrospective case study

Setting: An urban academic teaching hospital

Patients or Participants: Representative single case study of a primary MIGS patient with stage IV endometriosis previously treated with laparoscopic hysterectomy, who underwent laparoscopic surgical treatment involving the vaginal cuff for continued symptoms

Interventions: Partial peritonectomy (right side wall), Right ureterolysis

Measurements and Main Results: The patient's disease included a complex deeply infiltrating endometriotic lesion involving the right side of the vaginal cuff and a portion of the right ureter. We highlight the patient's disease progression and explore existing literature on prevalence, recurrence and prevention of vaginal cuff endometriosis. We showcase the surgical video of the case including partial peritonectomy and right ureterolysis to remove visible and palpable endometriotic disease. Biopsy results confirmed suspected endometriosis.

Conclusion: We showcase a unique case of vaginal cuff endometriosis recurrence after primary surgical treatment with hysterectomy. We synthesize our case and brief literature review to explore how our patient’s care could have been optimized. Specifically, we wonder if pelvic MRI at initial presentation may have helped elucidate evidence for deep infiltrating disease, and prompted more thorough disease resection or peritonectomy. We explore the role of ovarian preservation for our patient, as she had recurrence of endometrioma in her preserved right ovary, and later vaginal cuff disease. Most importantly, we highlight the importance of MIGS consult and repeat diagnostic laparoscopy in the setting of chronic pelvic pain consistent with endometriosis, even in patients with prior surgical treatment for endometriosis or comorbidities contributing to chronic pain. Our case demonstrates that significant relief of symptoms can be achieved from effective excision of endometriotic disease.