Video article – Laparoscopic excision of large ACUM masquerading as degenerated myoma: a case report

ABSTRACT
Objective. To demonstrate surgical procedure of laparoscopic excision of large ACUM. Accessory cavitating uterine mass (ACUM) is an underdiagnosed entity presenting with severe dysmenorrhoea in young women. Ultrasound and MRI often misdiagnose it as a rudimentary horn, noncommunicating horn, endometrioma, cystic adenomyosis or degenerated fibroid due to similar radiological appearance. Misdiagnosis and medical management prolong patient suffering hence correct diagnosis and excision of ACUM ensuring complete removal of cavity lining is essential for successful management.
Description of the case. 25-year-old woman, sexually inactive presented with complaint of severe dysmenorrhoea for 7 years and heavy menstrual bleeding for 2 years. 2 years prior patient was diagnosed as fibroid uterus on ultrasound and advised combined oral contraceptive pill for 3 cycles for heavy bleeding. Per rectal examination showed 12 weeks size uterus with mass in posterior wall. MRI reported a 5 × 4 cm posterior wall intramural myoma with cystic degeneration. Patient was planned for laparoscopic myomectomy.
Possibility of lesion being ACUM and need for its excision were explained to patient. During surgical dissection chocolate-coloured fluid drained from the
lesion suggesting ACUM. Histopathology confirmed the diagnosis of ACUM.
On follow up, 3 months later, patient was completely pain free and having regular menses.
Conclusions. This case is unusual as a large ACUM was located in the posterior wall abutting and splaying the endometrial cavity. Its location and appearance on MRI lead to the misdiagnosis of a myoma with cystic degeneration which is an important differential diagnosis for ACUM.

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