Case notes
An 82-year-old patient complained to her gynecologist about 6 months worsening vaginal prolapse, pelvic pressure, and a constant urge to void and defecate. She had used a pessary, which she was unable to replace. Pelvic examination revealed a gaping introitus with an apparent stage 3 posterior vaginal prolapse ( Figure 1 ). Speculum examination was not possible because of a mass displacing the vagina anteriorly. Magnetic resonance imaging showed a 16 × 8.8 × 6.5–cm cystic mass anterior to the rectum ( Figure 2 ). The differential diagnosis included a tailgut cyst vs rectal duplication.
The patient was taken to the operating room by a team of gynecologic oncologists and colorectal surgeons. They found a large mass in the left ovary, directly contiguous with the uterus and rectosigmoid colon that dissected the rectovaginal septum down to the perineum, ascites, an omental cake that involved the transverse colon, and enlarged periaortic lymph nodes. A total abdominal hysterectomy (bilateral salpingo-oophorectomy [ Figure 3 ], en-bloc resection of the tumor that included the rectosigmoid colon [ Figure 4 ], proctectomy with descending end colostomy omentectomy, periaortic lymphadenectomy, and tumor debulking) was performed. The final pathologic report confirmed a high-grade serous carcinoma that involved the ovaries, fallopian tubes, uterine serosa, rectosigmoid colon, and omentum. Periaortic and mesenteric nodes contained metastatic cancer. The patient was discharged from the hospital to a skilled nursing facility for short-term rehabilitation after 15 days and has just completed adjuvant carboplatin and paclitaxel.
