Title: Successful surgical treatment of postmyomectomy uterine diverticulum: A case report
Version: 1 Date: 24 Dec 2022
Reviewer's report:
A uterine diverticulum is a rare disease and can be congenital or acquired. There is no certain
consensus on their treatment. This case report describes a case of a uterine diverticulum in the
posterior wall of the uterus that developed after a laparotomic myomectomy. The authors report
that this is the first report of a uterine diverticulum after a myomectomy. The authors said that in
this case, the cyst was removed laparoscopically, and the torn myometrium was sutured without
postoperative recurrence.
Although this case report is valuable, there are several criticisms described below.
Abstract: The conclusion is that the mechanism is similar to that of cesarean scar syndrome
and that the same treatment as for cesarean scar syndrome is effective. It is unreasonable to
conclude that cesarean scar syndrome and uterine diverticulum are similar because the causes of
cesarean scar syndrome and uterine diverticulum, which occur during surgery during pregnancy,
are different and involve the same incision and suturing procedure. The conclusion should be
changed.
Background: You state that this is the first case of diverticulum uteri after myomectomy in the
world, but on page 8, line 15, you say that the incidence of diverticulum uteri after myomectomy
is 18%. An appropriate response to this discrepancy is needed.
Case presentation:
#1. The pregnancy history states that the patient had an ectopic pregnancy, but the site of the
pregnancy and the type of treatment should be described in detail.
#2. Myoma should be described as fibroid.
#3. The product name of the GnRH agonist before myoma enucleation and the duration of
administration should be stated. It is better to mention whether this GnRHagonist reduced the
size of the myoma and how many centimeters it was just before the surgery.
#4. If there are symptoms such as anemia, it is reasonable to administer GnRHagonsit. Still,
please describe the reason why GnRHagonist was issued before the surgery if the surgery was
abdominal enucleation.
#5. If you have information, please tell the sutures used in the abdominal myomectomy by
product name.
#6. Menstruation resumed about one month after the myomectomy. Please state when the
last GnRHagonsit was administered before surgery. Discuss in your discussion whether early
resumption of menstruation may be related to the development of uterine diverticulum.
#7. Provide the product name of the thread used to suture the torn muscle layer in the surgery
for the uterine diverticulum.
#8. Describe the laparoscopic procedure, trocar placement, pneumoperitoneum, and energy
devices used in the incision of the uterine diverticulum.
#9. Although menstruation occurred ten days after the surgery for uterine diverticulum, you
dared to perform the surgery in the luteal phase, and please describe the reason for this, if any.
#10. The last sentence of the case presentation (lines 6-7 on page 8) is an assumption by the
author, is inappropriate for the case presentation, and should be deleted.
Discussion and conclusions
#1. On line 15 on page 8, you state that the frequency of uterine diverticulum after myomectomy
is 18%. Discuss the consistency of this with the present case.
#2. Many paragraphs discuss the similarity to cesarean scar site syndrome. Instead of discussing
the similarities in the etiology of cesarean scar site syndrome and uterine diverticulum, you
should consult the differences.
#3. Discuss the pathological diagnosis of the uterine diverticulum.
#4. Discuss the presence or absence of functional endometrium within the diverticulum,
abnormal uterine bleeding, etc.
#5. Cite and discuss the following article. A case report of a congenital diverticulum of the uterus
treated laparoscopically.
"Keiko Tanaka, Naomi Shiga, Takashi Kuno, Zen Watanabe, Masahito Tachibana, Nobuo
Yaegashi. J Obstet Gynaecol Res. 2020 Aug;46(8):1460-1464. DOI: 10.1111/jog.14255."