Successful surgical management of a septate uterus constricted with leiomyomas: hysteroscopic metroplasty using a Foley catheter

Abstract

A septate uterus, which is the most common congenital uterine anomaly, is associated with impaired reproductive outcome, such as spontaneous abortions and preterm delivery [1]. Accumulating evidence suggests that septal implantation is a possible cause of such reproductive disorders [2]. Hysteroscopic metroplasty (resection of the septum using a resectoscope) has been widely accepted because of its simplicity and low level of invasiveness [3, 4]. However, hysteroscopic surgery for a septate uterus complicated with leiomyomas, which cause constriction of the uterine cavity, can be challenging. A 37-year-old nulligravida female had been suffering from hypermenorrhea and infertility. Magnetic resonance imaging (MRI) revealed a complete uterine septum continuing to the vaginal septum without a fundal cleft (Fig. 1a, b). A 30-mm intramural myoma node (myoma 1 in Fig. 1b, g) localized just dorsal of the uterine septum caused a deformity of the intrauterine cavity. Moreover, an intraligamentary myoma node (myoma 2 in Fig. 1a, g) measuring 70 mm in diameter caused the compression of the uterus. The patient elected to undergo endoscopic surgery, including metroplasty and myomectomy, rather than a laparotomy, and also wanted to complete the resection of the uterine septum and myoma nodes at one time. First, resectoscopy was performed under pneumoperitoneal laparoscopy. The 9-mm rigid, 12 resectoscope with a loop electrode (Olympus, Tokyo, Japan) was inserted into the left uterine cavity. On the other hand, the cavity between the uterine septum and the right wall of the myometrium could not be detected because of constriction of the cavity by leiomyomas. Therefore, the resectoscope could not be inserted into the right cavity. To improve intra-operative orientation, a pediatric 6-Fr Foley catheter was inserted as a guide in the right uterine cavity and was directed to the uterine fundus (Fig. 1c–e). Without damage to other parts of the inside uterus or misdirection, hysteroscopic metroplasty and resection of the submucosal myoma (myoma 3 in Fig. 1b, g) was successfully performed using a 40-watts cut mode, followed by laparoscopic myomectomy for myoma 1, 2 and 4 in Fig. 1a, b, and g. A post-operative MRI showed a normal shaped uterus, with \1 cm residual uterine septum located in the fundus (Fig. 1f). A spontaneous pregnancy has been achieved after operation. The course of the pregnancy was uneventful until 35 weeks’ gestation. The patient then had severe vaginal bleeding at 36 weeks’ gestation and therefore, an emergency Cesarean section was performed although no uterine contraction or abdominal pain was accompanied. No intraperitoneal adhesion was found. No abnormal findings or scar of the myometrium was found, either. Blood loss during surgery was 515 g. The patient’s post-operation course was uneventful, and the patient was discharged on the seventh day after the Cesarean section. Our case showed a complete uterine septum and leiomyomas. Each leiomyoma affected the safety of the hysteroscopic metroplasty, considering that one of the most important aspects of resectoscopic surgery is the uncompromised visibility of the surgical field. An intramural myoma node located just beneath the uterine septum and a A. Iwase (&) M. Goto S. Manabe H. Kobayashi M. Kondo F. Kikkawa Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan e-mail: akiwase@med.nagoya-u.ac.jp