Author
Information
Anuya
Pawde*, Neha Saxena**, Sarita Channawar***, A.R.Chauhan****
(* Senior Registrar, **
Registrar, *** Assistant Professor, Additional Professor. Department of
Obstetrics and Gynecology, Seth G.S. Medical
College and K.E.M
Hospital , Mumbai , India
Abstract
Cervical
fibroids are difficult to diagnose and manage surgically. Management depends
upon presentation and desire of fertility. Myomectomy for preservation of
fertility is difficult in cases of giant as well as cervical fibroid. A 27
year-old unmarried girl presented with hemorrhagic shock, menorrhagia and giant
cervical fibroid. This case illustrates surgical difficulties especially when
uterine conservation is needed, emphasizing the need to follow principles of
myomectomy.
Introduction
Though
fibroids are the commonest benign tumors of the uterus, cervical fibroids
constitute only 1-2% of all fibroids. They are classified as anterior,
posterior, lateral and central depending on their location. They may remain
asymptomatic till they enlarge and present with menorrhagia, dysmenorrhea or
pressure symptoms, mainly bladder related; diagnosis is often missed prior to
surgery. [1] Pelvic anatomy is disturbed especially in interstitial
type of cervical fibroid; surgery is confounded by a pulled up, stretched
bladder and displaced ureters, increasing the risk of injury. [2]
Management is usually surgical as medical and other interventional treatments
like uterine artery embolization (UAE) and high intensity focused ultrasound
(HIFU) usually fail by virtue of size and location of fibroids; myomectomy is
indicated for fertility conservation.
Case
Report
A 27
year old unmarried girl presented with hemorrhagic shock and active vaginal
bleeding. She had dysmenorrhea and severe menorrhagia since one year, increased
in intensity over last 6 months. There were no urinary complaints. She was
previously diagnosed on MRI with single giant fibroid (20 x 20cm) not amenable
to HIFU hence was advised hysterectomy elsewhere; however in view of her young
age and unmarried status, she and her parents refused surgery. Subsequently,
she did not take any treatment.
On
admission, she had tachycardia (110/min), hypotension (blood pressure 90/60mm
Hg) and severe pallor. Abdominal examination revealed a firm, smooth,
nontender, relatively immobile mass arising from pelvis corresponding to 32 -34
weeks’ size uterus. She was stabilized and managed conservatively with 4 units
of blood (admission hemoglobin 4g %), intravenous tranexamic acid and injection
leuprolide acetate 3.25mg intramuscularly; surgery was deferred in view of
severe anemia. She was discharged and asked to follow-up on completion of oral
iron therapy and 3 doses of injection leuprolide.
However,
she presented in the next cycle with similar complaints; uterine size had only
slightly reduced (30 weeks). Hemoglobin was 10.6g %, repeat ultrasound
suggested huge intramural fibroid of size 20 x 15cm, pushing uterus towards right,
with bilateral hydronephrosis and hydroureters. Hence myomectomy with
preoperative ureteric stenting was advised; she refused stenting but after
counseling, agreed to surgery.
Abdomen
was opened through midline vertical incision, extended supraumbilically. In
situ findings: normal-sized uterine fundus sitting on top of giant 20x18cm
central cervical fibroid, the classically described lantern on top of the dome
of St Paul’s cathedral. Uterine fundus was deviated to the right side, bulk of
the growth extended to the left broad ligament, and bilateral adnexae were
stretched over fibroid with urinary bladder pulled upward. Uterovesical fold of
peritoneum was opened and bladder was mobilized inferiorly. Injection
vasopressin 20units in 20ml normal saline was injected in the region of uterine
arteries with due care. Vertical incision of approximately 12-15cm was taken
over anterior wall of fibroid (4-5cm inferior to fundus). Giant myoma weighing
2.5kg was enucleated easily. Anatomy was identified: entire cervix replaced by
myoma, uterine body with anteriorly opened cavity and intact posterior wall was
seen on superolateral aspect of a huge myoma bed, with only well-defined intact
external os in the base of bed. Both uterus and cervical os were held with Babcock
forceps. Hemostasis was achieved by obliterating the myoma bed with series of
figure-eight and purse-string sutures using No. 1 polygalactin 910; redundant
myoma wall was excised. Reanastomosis of uterine cavity and external os was
begun on posterior inner wall, with sutures of No. 1 polyglactin taken
anteroposteriorly (vertically) and circumferentially. Pediatric Foley catheter
No. 10 was inserted as a stent in the uterine cavity, and bulb was inflated
with 5ml normal saline. Open end of the catheter was then inserted in a
retrograde manner though external os and brought out into vagina.
Circumferential anastomosing sutures were carried anteriorly over the stent
taking care not to pierce the catheter. Reinforcing sutures were taken and
complete anastomosis was achieved. Serosa was closed with No. 2-0 polyglactin
910. Bilateral ureters were traced and found normal.
Figure
1: Giant cervical fibroid.
Figure
2: Opened uterine cavity and myoma bed.
Figure
3. External cervical os.
Figure
4. Uterocervical anastomosis with artery forceps in os.
Figure
5. Foley catheter as stent.
Figure
6. Complete closure.
Postoperative
period was uneventful; ultrasound examination on post-operative day 6 showed
catheter in place, with a small collection lateral to cervix. Patient was
discharged on day 10 with catheter in situ which was removed easily on day 21.
Repeat USG showed resolving collection with reanastomosed uterus. Patient
resumed normal menses 6 weeks after the procedure, without menorrhagia or
dysmenorrhoea. Histopathology revealed degenerated myoma. Patient is on oral
contraceptive pills and regular follow-up.
Figure
7. Postoperative USG with catheter in situ.
Figure
8. Postoperative USG showing successful anastomosis.
Discussion
Myomectomy
for fertility preservation can be challenging in cases of giant and cervical
fibroids. Preoperatively, GnRH analogues
may reduce both the size and vascularity, and thus pre and intraoperative blood
loss. [2] UAE reduces blood loss as well of need of surgery in
fibroids, however data related to future fertility is unclear. [3]
Very
few cases have been reported for giant cervical fibroid. Hysterectomy is
usually resorted to and reconstruction of cervix and uterus is a rarity. [4,
5, 6] Surgical reanastomosis requires thorough knowledge of anatomy and
is technically challenging. The technique used by us has not been described
earlier. Integrity of utero-cervical anastomosis was confirmed with restoration
of patient’s menstrual function; however her future reproductive function is
still uncertain.
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Falcon T and Parker WH. Surgical management of
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Ustunsoz A. Is uterine artery embolization prior to myomectomy for giant
fibroids helpful? Diagn Interv Radiol. 2007;13(4):210-226.
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Vassilev B, Doganov N. Surgical anastomosis between cervix and corpus uteri
(Metro-anastomosis, isthmico cervicalis) (author's transl). Zentralbl Gynakol.
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Citation