You are on page 1of 5

European Journal of Obstetrics & Gynecology and Reproductive Biology 200 (2016) 123127

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and


Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Adnexal masses requiring reoperation in women with previous


hysterectomy with or without adnexectomy
Linda-Dalal J. Shiber a,1,*, Emily J. Gregory a,2, Jeremy T. Gaskins b, Shan M. Biscette a
a
University of Louisville School of Medicine, Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Louisville,
KY 40202, United States
b
University of Louisville School of Public Health and Information Sciences, Department of Bioinformatics and Biostatistics, Louisville, KY, United States

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 9 February 2016
Received in revised form 25 February 2016
Accepted 29 February 2016

Objectives: To characterize the etiologies of adnexal masses requiring reoperation in women with prior
hysterectomy and to compare incidence and pathology of these masses based upon whether total, partial
or no adnexectomy was performed at time of hysterectomy. In addition, the average time interval
between hysterectomy and reoperation for a pelvic mass is ascertained.
Study design: A single-institution, retrospective review spanning 10 years. Using pertinent ICD-9 and
CPT codes, women with a history of hysterectomy who underwent a subsequent surgery for an adnexal
or pelvic mass were identied.
Results: Over ten years, 250 women returned for gynecologic surgery due to a pelvic mass after prior
hysterectomy. Most had undergone hysterectomy only (76%). 64.8% of these women had masses of
ovarian origin, 12.4% were tubal in origin, 20% of masses involved both the ovary and tube and a small
proportion arose from non-gynecologic processes. 18% of these women had a malignancy; 80% were
ovarian and 6.7% originated from the fallopian tube. Patients having had a prior hysterectomy and
bilateral salpingectomy returned soonest (p < 0.0001) and patients with malignant masses returned
after the longest time intervals (HR 0.41, p < 0.0001).
Conclusions: The majority of adnexal masses requiring reoperation after hysterectomy are gynecologic
in origin, benign, and arise from the ovary. Women returning with malignant masses after hysterectomy
present after longer time intervals.
2016 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Adnexal mass
Pelvic mass
Prior hysterectomy
Prophylactic salpingectomy
Reoperation
Salpingectomy at hysterectomy

Introduction/background
Hysterectomy is one of the most common surgeries performed
in the United States [1]. It is often viewed by women as a cure, and
the nal management option, for many gynecologic complaints.
Despite this widely held belief, it is not uncommon for further
gynecologic surgery to occur following hysterectomy. These
subsequent abdominal surgeries are often associated with
increased risks of intraoperative complications related to adhesive

This research was presented as an oral presentation at the 82nd Annual Meeting
of the Central Association of Obstetricians and Gynecologists, Charleston, SC,
October 2124, 2015.
* Corresponding author at: 2500 Metrohealth Drive, Cleveland, OH 44113,
United States. Tel.:+12167784444.
E-mail address: lindashiber@gmail.com (L.J. Shiber).
1
Present address: Metrohealth Hospital, Division of Minimally Invasive Surgery,
Department of Obstetrics and Gynecology, Cleveland, OH 44109, United States.
2
Present address: University of Tennessee, Department of Obstetrics and
Gynecology, Knoxville, TN 37920, United States.

http://dx.doi.org/10.1016/j.ejogrb.2016.02.043
0301-2115/ 2016 Elsevier Ireland Ltd. All rights reserved.

disease and distortion of anatomy [24]. Adnexal or pelvic masses


are common reasons women require further surgery following
hysterectomy and their frequency may depend upon whether
total, partial or no adnexectomy is performed at hysterectomy.
Salpingectomy at the time of hysterectomy has emerged as a safe,
low risk technique to decrease the risk of needing future surgery for
benign adnexal masses and, most importantly, ovarian cancer risk
[5,6]. The Society of Gynecologic Oncology (SGO) states that women
with BRCA1 and 2 mutations receive signicant cancer risk
reduction if salpingectomy  oophorectomy is performed [7]. Furthermore, in women at average risk for ovarian cancer, salpingectomy
at the time of hysterectomy or even sterilization could prove benecial
and should be offered routinely. This recommendation has been echoed
by the American College of Obstetricians and Gynecologists as well [8].
It is accepted that the fallopian tube serves no purpose after the
completion of childbearing, and may incur other risks besides a
potential cancer risk, including hydrosalpinx, tubal pregnancy,
torsion, chronic PID, salpingitis, tubal prolapse, TOA [9]. The
incidence of these problems has been examined in several studies.

124

L.-D.J. Shiber et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 200 (2016) 123127

A large Danish historical cohort study found that women who had
hysterectomy without salpingectomy had a more than double risk
of subsequent surgery for tubal disease than women undergoing
bilateral salpingectomy at the time of hysterectomy [10]. Another
study found that women undergoing salpingectomy with hysterectomy had lower rates of all type of infectious morbidity [11].
Morse et al. found that the lifetime risk of a woman returning to the
operating room for surgical management of hydrosalpinx after
hysterectomy approached 8% [12]. A 2014 study reviewing
295 patients demonstrated a higher incidence of benign adnexal
pathologies in women who had not had prophylactic salpingectomy (26.9%), versus those who had undergone prophylactic
bilateral salpingectomy (13.9%, p = 0.02) [13].
Conversely, the risks associated with salpingectomy are low.
Arguments that removing the fallopian tube might decrease
ovarian blood supply and thereby precipitate premature ovarian
failure have been dispelled by multiple studies [1416]. Salpingectomy at the time of hysterectomy adds minimal time to the
procedure and is not associated with a signicant increase in blood
loss or length of hospital stay [9]. A recent study examining cost
and ovarian cancer risk reduction of salpingectomy at hysterectomy versus hysterectomy alone and hysterectomy + BSO found that
performing salpingectomy at time of hysterectomy was less costly
and provided greater reduction in risk [17].
These ndings indicate the benign practice of salpingectomy at
time of hysterectomy may decrease future need for gynecologic
surgical intervention with no signicant risks to the patient,
certainly when compared with the morbidity associated with
additional surgery. A small Pakistani study performed in
2004 underlined the signicant risks posed to women presenting
for repeat pelvic surgery status post hysterectomy. This retrospective review spanning 3 years found that 43 women with a prior
hysterectomy returned with adnexal masses and 19 required
further surgery. The majority of lesions were ovarian in origin and
benign; 32% were malignant and 16% were related to dilatation of
the fallopian tube. In addition, complication rates during and after
reoperation were high, with two women suffering small bowel
injuries, two post-operative wound infections and one deep vein
thrombosis post-operatively [18].
At our academic institution, patients with complex gynecologic
pathology including malignancies and post-hysterectomy adnexal
masses are often referred from outside facilities for surgical
management. These complex cases pose a challenge for even
seasoned gynecologic surgeons and incur risk to the patient as well
as increased healthcare costs. The practice of performing bilateral
salpingectomy at the time of hysterectomy was adopted early at
this hospital, however many of the women returning with complex
masses underwent hysterectomy at other institutions and return
after varying time intervals, making it difcult to estimate the
effects of our change in practice over time.
This study, thus, aims to review the cases of all women
presenting to our institution for surgical management of an
adnexal mass after a prior hysterectomy. The primary objective is
to characterize the etiologies (gynecologic versus non-gynecologic,
benign versus malignant) of these masses and to compare
incidence and pathology in terms of whether total, partial or no
adnexectomy was performed previously. Secondarily, the average
time interval between hysterectomy and reoperation for a pelvic
mass, stratied by pathologic diagnosis and extent of previous
surgery, is ascertained.
We hypothesize that amongst women undergoing reoperation
for adnexal masses post-hysterectomy, most will have undergone
hysterectomy alone without unilateral/bilateral adnexectomy or
salpingectomy. We postulate that most masses will be benign and
of ovarian origin and that the smallest subgroups of women
requiring reoperation will be comprised of women with prior

bilateral salpingo-oophorectomy or bilateral salpingectomy, supporting the effects of removal of fallopian tubes on the risk of
future reoperation.
Materials and methods
A single-institution, retrospective review spanning 10 years,
20032013, was performed at University of Louisville Hospital, an
urban, academic institution. This hospital serves as a state-wide
referral center for women with complicated gynecologic surgical
needs, including gynecologic malignancies. A fair proportion of the
patient population does not present for regular health maintenance exams and many return with advanced, complicated
adnexal masses.
For this review, expedited IRB approval was obtained
(IRB#14.0640). Using pertinent ICD-9 and CPT codes corresponding to surgery for benign and malignant adnexal pathology
(789.39, 789.30, 614.1, 614.2, 620.8, 620.9, and 620.2 and
58700, 58720, 58661, 49320, 49322, and 58862, respectively), a
medical record query was performed to identify women with a
history of hysterectomy who underwent a subsequent surgery for
an adnexal or pelvic mass.
Women who were eligible for this study were those with a prior
hysterectomy who had subsequently undergone reoperation for an
adnexal mass at University of Louisville from the years 2003 to
2013. Women undergoing surgery for an adnexal mass without a
previous hysterectomy, unavailable operative or pathology reports
from reoperation and any cases occurring outside of above date
range were excluded from the study.
After medical records compiled a list of patients meeting the
above criteria and diagnosis codes, charts were reviewed for
presenting complaints, surgical ndings, pathology reports and
surgical history. The remaining women were divided into groups
based upon whether they had previously undergone hysterectomy alone, hysterectomy plus bilateral salpingo-oophorectomy
(hyst + BSO), hysterectomy plus unilateral salpingo-oophorectomy (hyst + USO) or hysterectomy plus bilateral salpingectomy
(hyst + BS). The indication for hysterectomy and time interval
between hysterectomy and reoperation were collected when
available.
Statistical analysis was performed by a statistician who
regularly collaborates with the department. Differences in time
interval from hysterectomy to reoperation as well as differences in
age at return according to previous surgery type were examined
using the log-rank test and hazard ratios from the Cox survival
model.
Results
Over ten years, 250 women with a previous hysterectomy
presented to this institution with a pelvic mass requiring
additional surgery. The majority had undergone hysterectomy
alone (n = 190, 76%). 44 (17.6%) had hysterectomy + USO in the
past, 10 (4%) had hysterectomy + BSO, and 6 (2.4%) had hysterectomy + BS (Table 1, Fig. 1).
Indication for prior hysterectomy was available in 122 (48.8%)
of women with most common surgical indications being abnormal
bleeding (n = 33, 27%) and uterine leiomyoma (n = 30, 24.6%). Of
the women with a known indication for index hysterectomy, 8
(6.6%) underwent hysterectomy for a gynecologic malignancy.
Upon reoperation, only one of those women had a malignant mass;
6 were benign, 1 was borderline (Table 1).
The majority of adnexal masses arising after hysterectomy and
requiring surgery were benign (n = 205, 82%) while 18% were
malignant (n = 45). Most masses were ovarian in origin (64.8%) and
these ovarian masses accounted for 63.4% of benign and 80% of

L.-D.J. Shiber et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 200 (2016) 123127

125

Table 1
Age, time to reoperation, and etiology of masses in patients presenting for surgical management.
Hysta only

Total
N (% of total)
Mean age at return (SD)

250
53.4 (15.2)

Indication for hysterectomy N (% of total subjects)


Abnormal bleeding
Fibroids
Prolapse
Endometriosis
Pain
Cervical dysplasia
Hemorrhage
Infection
Mass
Malignancyb

122
33
30
13
15
7
11
2
1
2
8

Reoperation
Years to reoperation [range]c
Initial operation date [range]c
Initial operation date missing (%)

190 (76)
55.6 (14.9)

(48.8%)
(27%)
(24.6%)
(10.7%)
(12.3%)
(5.7%)
(9.0%)
(1.6%)
(.8%)
(1.6%)
(6.6%)

14 [429.75]
1995 [19802004]
76 (30.4)

90
28
25
11
5
4
9
2

(47.4%)
(31.1%)
(27.8%)
(12.2%)
(5.6%)
(4.4%)
(10%)
(2.2%)

(6.7%)

20 [731]
1992 [19782001]
59 (31.1)

Hyst + USOa
44 (17.6)
47.6 (14.3)
24
3
5
2
7
3
2

1
1

(54.5%)
(12.5%)
(20.8%)
(8.3%)
(29.2%)
(12.5%)
(8.3%)

(4.2%)
(4.2%)

5 [219]
2001 [19902006]
15 (34.1)

Hyst + BSOa
10 (4)
45.8 (17.6)
6
1

1
1
1

(60%)
(16.7%)

(33.3%)

(16.7%)
(16.7%)
(16.7%)

4.5 [3.758.25]
2004 [20002006]
2 (20)

Hyst + BSa
6 (2.4)
39.0 (6.8)
2 (33.3%)
1 (50%)

1 (50%)

1.5 [15]
2008 [20042011]
0 (0)

Tumor type N (%)


Benign
Malignant

205 (82)
45 (18)

150 (78.9)
40 (21.1)

41 (93.2)
3 (6.8)

8 (80.0)
2 (20.0)

6 (100)
0 (0)

Origin N (%)
Ovarian
Tubal
Ovarian + tubal
Other
Non-gynecologicd

162
31
50
2
4

120
27
39
1
3

29
3
11
0
1

7
1
1
1
0

6
0
0
0
0

(64.8)
(12.4)
(20.0)
(.8)
(1.6)

(63.2)
(14.2)
(20.5)
(.5)
(1.6)

(65.9)
(6.8)
(25)
(0)
(2.3)

(70)
(10)
(10)
(10)
(0)

(100)
(0)
(0)
(0)
(0)

a
Hyst, hysterectomy; hyst + USO, hysterectomy + unilateral salpingo-oophorectomy; hyst + BS, hysterectomy + bilateral salpingectomy; hyst + BSO, hysterectomy + bilateral salpingo-oophorectomy.
b
For women with cancer as indication for hysterectomy, 6/8 masses requiring reoperation were benign, 1/8 was malignant and 1/8 was borderline.
c
Due to lack of normality, the median and rst and third quartiles are shown.
d
For non-gynecologic masses, 1/4 was benign (peritoneal inclusion cyst), 3/4 were malignant (B-cell lymphoma, colon cancer, breast cancer).

malignant masses overall. 12.4% of masses arose from the fallopian


tube and comprised 6.7% of malignant and 12.9% of benign masses.
Masses involving both the fallopian tube and ovary made up 20% of
reoperations and were responsible for 6.7% of malignancies and
21.6% of benign masses. Other etiologies (n = 2, 0.8%) included
benign broadipose tissue and a vaginal cuff leiomyoma. Nongynecologic causes (n = 4, 1.6%) were rare and included 3 cases of
metastatic cancer (B-cell lymphoma, colon and breast) and a
benign peritoneal inclusion cyst (Table 1).

[(Fig._1)TD$IG]

Fig. 1. Initial surgery by type and year. Bar graph depicting number of patients who
returned for reoperation by year of their hysterectomy (depicted in 5 year
increments) and type of index surgery (i.e., hysterectomy only, hysterectomy
and unilateral or bilateral salpingo-oophorectomy, hysterectomy and bilateral
salpingectomy).

Age at repeat surgery was compared between women with


malignant, benign or inammatory masses using the log-rank test.
Median age of women returning with malignant adnexal masses
was signicantly higher at 69 years than those with benign/
inammatory masses [median 48.5 and 44 years, respectively.
p < 0.0001]. In addition, age at repeat surgery was different based
upon index surgery type, i.e., hysterectomy alone, hyst + BSO,
hyst + USO, hyst + BS with women having had prior hysterectomy
alone returning at older ages than the other subgroups
[p < 0.0001]. However, when the age at initial surgery was
considered, there was no signicant difference between groups.
The time interval between hysterectomy and subsequent
adnexal mass surgery was examined for differences between
subgroups; year of hysterectomy was available in 174 women.
Using the log-rank test, there was strong evidence that time
interval between hysterectomy and adnexal mass surgery differed
between groups (p < 0.0001). Patients with a prior hysterectomy
and bilateral salpingectomy returned with adnexal masses
4.6 times sooner than women undergoing hysterectomy alone.
Patients who had hysterectomy + BSO and those with hysterectomy + USO returned 2.9 and 1.5 times sooner, respectively, than
women in the hysterectomy-only group (Fig. 2). These ndings are
likely confounded by the fact that most hysterectomy + BS
surgeries were performed more recently, with a shorter interval
to reoperation. In particular, the median year of initial surgery was
1992 for the hysterectomy-only patients compared to 2001 for
hysterectomy + USO, 2006 for hysterectomy + BSO, and 2008 for
hysterectomy + BS.
Time interval between hysterectomy and reoperation also
differed based upon type of adnexal mass, with women having
malignant masses returning after the longest time intervals (HR
0.41, p < 0.0001, Fig. 3). There was no evidence of a difference in
return time by mass anatomic origin (p = 0.296).

[(Fig._2)TD$IG]

126

L.-D.J. Shiber et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 200 (2016) 123127

Fig. 2. Median time interval from index surgery to reoperation. Bar graph showing
median time in years between hysterectomy and reoperation, grouped by type of
index surgery and type of pelvic mass.

Comment
Hysterectomy is often a denitive surgery for women and the
nal option for a myriad of pathology. It can be extrapolated that
women undergoing hysterectomy have the expectation they will
not require future surgery for gynecologic problems; however, this
is not necessarily true. In this review, over 10 years, 250 women
with a history of hysterectomy returned with adnexal masses
requiring surgery; only a minority (1.6%) were non-gynecologic in
origin and most masses were benign, arising from ovarian tissue.
It is known that additional surgery is associated with additional
risk related to adhesive disease, anesthesia and preexisting
medical co-morbidities [24]. Furthermore, healthcare costs rise
with each surgical intervention. If gynecologic surgeons can reduce
the likelihood of a subsequent surgery with benign intervention at
the time of hysterectomy, this can make a great difference in risk
reduction and cost.
Bilateral salpingectomy at the time of hysterectomy has been
advocated in recent years as an intervention that can provide
benet in decreasing the risk of serous carcinoma as well as benign

[(Fig._3)TD$IG]

pathology that may require future surgery [514]. This procedure


has been shown to be efcient and safe, adding minimal procedural
time and virtually no risk [1517].
In our cohort, only six women with bilateral salpingectomy at
the time of hysterectomy returned with adnexal masses requiring
reoperation; all of those masses were benign ovarian remnants.
This is in contrast to the 190 women with prior hysterectomy
alone, 40 of whom returned with malignant adnexal masses.
This study is the second to examine the causes for posthysterectomy adnexal masses requiring surgery and the rst to
stratify reoperation incidence based upon whether the adnexa
were completely or partially resected. One prior review, spanning
only three years and examining a non-US population, looked at the
pathologic etiologies of pelvic masses in women after prior
hysterectomy [18]. That study predated the consensus that
fallopian tube removal with hysterectomy should be considered
for all women.
The limitations of this study are centered upon its retrospective
nature and the presence of unidentied confounding factors that
may have impacted our ndings. First, it was not possible to
identify a baseline n representing the total number of women
undergoing hysterectomy against which we might compare the
percent of women returning for reoperation for adnexal masses.
Many women undergoing reoperation at our hospital had
hysterectomies at other institutions and/or decades prior. We
therefore cannot quote a percent risk of requiring future surgery
based upon whether bilateral, unilateral or partial adnexectomy is
performed at time of hysterectomy.
Secondly, the number of women returning for surgery in the
hysterectomy + bilateral salpingectomy group was very small. This
may reect a decreased risk for future surgery among that cohort
or it may simply indicate an insufcient time interval since this
practice was adopted to truly evaluate how many women will
return with adnexal masses in the future.
Despite the intrinsic limitations of our retrospective study, we
believe our ndings have implications for hysterectomy care and
patient counseling. This study provides additional information
regarding what brings women back for gynecologic surgery
following hysterectomy and this is important in discussing the
long term benets and risks of hysterectomy with no, partial or
bilateral adnexectomy. It is interesting to nd that the majority of
our cohort undergoing reoperation after hysterectomy had benign
masses that were ovarian in origin. Though routine salpingectomy
at hysterectomy can decrease the potential risk of repeat surgery
for masses of tubal origin, based on our ndings, it is unlikely to
affect the majority of future reoperations for post-hysterectomy
adnexal masses. That said, we agree with current guidelines and
support routine salpingectomy at hysterectomy as a strategy to
decrease later occurrence of benign pathology as well as ovarian
cancer [7,8]. We believe that future, prospective research is
necessary to examine the long-term effects, potential for decreased
re-operative morbidity and healthcare cost savings of this change
in practice.
Conict of interest
The authors report no conict of interest
Funding
No funding sources for this study.
References

Fig. 3. Median time interval from index surgery to reoperation by mass type. Bar
graph showing median time in years between hysterectomy and reoperation,
grouped by type of pelvic mass only.

[1] Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 20002004. Am J Obstet Gynecol 2008;198:34e17.

L.-D.J. Shiber et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 200 (2016) 123127
[2] Brill AI, Nezhat F, Nezhat CH, Nezhat C. The incidence of adhesions after prior
laparotomy: a laparoscopic appraisal. Obstet Gynecol 1995;85:26972.
[3] Davey AK, Maher PJ. Surgical adhesions: a timely update, a great challenge for
the future. J Minim Invasive Gynecol 2007;14:1522.
[4] Diamond MP, Wexner SD, diZereg GS, et al. Adhesion prevention and reduction: current status and future recommendations of a multinational interdisciplinary consensus conference. Surg Innov 2010;12(3):1838.
[5] Erickson BK, Conner MG, Landen Jr CN. The role of the fallopian tube in the
origin of ovarian cancer. Am J Obstet Gynecol 2013;209:40914.
[6] Kindelberger DW, Lee Y, Miron A, et al. Intraepithelial carcinoma of the mbria
and pelvic serous carcinoma: evidence for a causal relationship. Am J Surg
Pathol 2007;31(2):1619.
[7] SGO clinical practice statement: salpingectomy for ovarian cancer prevention;
2013, November, https://www.sgo.org/clinical-practice/guidelines/sgoclinical-practice-statement-salpingectomy-for-ovarian-cancer-prevention/.
[8] Salpingectomy for ovarian cancer prevention. Committee opinion no. 620. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:27981.
[9] Berlit S, Tuschy B, Kehl S, Brade J, Sutterlin M, Hornemann A. Laparoscopic
supracervical hysterectomy with concomitant bilateral salpingectomy why
not? Anticancer Res 2013;33(6):27714.
[10] Guldberg R, Wehberg S, Skovlund CW, Mogensen O, Lidegaard O. Salpingectomy as standard at hysterectomy? A Danish cohort study, 19772010. BMJ
2013;3:e002845.

127

[11] Ghezzi F, Cromi A, Siesto G, Bergamini V, Zero F, Bolis P. Infectious morbidity


after total laparoscopic hysterectomy: does concomitant salpingectomy make
a difference? BJOG: Int J Obstet Gynaecol 2009;116(4):58993.
[12] Morse AN, Schroeder CB, Magrina JF, Webb MJ, Wollan PC, Yawn BP. The risk of
hydrosalpinx formation and adnexectomy following tubal ligation and subsequent hysterectomy: a historical cohort study. Am J Obstet Gynecol
2006;194:12736.
[13] Vorwergk J, Radosa MP, Nicolaus K, et al. Prophylactic bilateral salpingectomy
(PBS) to reduce ovarian cancer risk incorporated in standard premenopausal
hysterectomy: complications and re-operation rate. J Cancer Res Clin Oncol
2014;140(5):85565.
[14] Dietl J, Wischhusen J, Hausler SF. The post-reproductive fallopian tube: better
removed? Hum Reprod 2011;26(11):291824.
[15] Findley AD, Siedhoff MT, Hobbs KA, et al. Short-term effects of salpingectomy
during laparoscopic hysterectomy on ovarian reserve: a pilot randomized
controlled trial. Fertil Steril 2013;100:17048.
[16] Morelli M, Venturella R, Mocciaro R, et al. Prophylactic salpingectomy in
premenopausal low-risk women for ovarian cancer: primum non nocere.
Gynecol Oncol 2013;129:44851.
[17] Kwon JS, McAlpine JN, Hanley GE, et al. Costs and benets of opportunistic
salpingectomy. Obstet Gynecol 2015;125:33845.
[18] Naz F, Begum A. Experience with pelvic masses following hysterectomy for
benign disease. Biomedica 2004;20:1069.