Technical Challenges in Hysteroscopic Myomectomy with Prolapsing Cervical Fibroid

Abstract

<h3>Study Objective</h3> To demonstrate various techniques to overcome challenges encountered during hysteroscopy myomectomy for multiple fibroids with concurrent prolapsing cervical fibroid. <h3>Design</h3> Stepwise demonstration using narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> A 44-year-old G4P2022 presented with heavy menstrual bleeding reporting heavier menses over the last few years. Pelvic exam demonstrated a 4 cm prolapsing cervical fibroid and a 12-week size multi-fibroid uterus. Pelvic MRI showed a multi-fibroid uterus with at least 30 myomas, including 5 submucosal fibroids measuring between 1-3 cm each. There was also a 3.7 cm pedunculated fibroid prolapsing through the cervix, into the vagina. Patient declined hysterectomy and opted for conservative surgical management. She underwent excision of prolapsing fibroid, hysteroscopic myomectomy, hysteroscopic endometrectomy, and levonorgestrel IUD placement. <h3>Interventions</h3> Below are strategies to remove multiple submucosal fibroids hysteroscopically when the cervix is dilated due to a prolapsing fibroid. 1. Two 0 PDS Endo-Loops are secured at the base of the prolapsing fibroid. The stalk is transected, and the fibroid is removed. 2. A purse string suture is placed around the cervix using 0 PDS and tagged with a hemostat at 12 o'clock. Once the hysteroscope is placed through the dilated cervix, the purse string suture is tightened, preventing leakage of hysteroscopic fluid. 3. Fibroids greater than 3 cm are enucleated at the base. Once the fibroid is free floating in the cavity, it can be grasped with a forcep and removed intact through the dilated cervix. Smaller submucosal fibroids are excised using hysteroscopic morcellator. <h3>Measurements and Main Results</h3> All submucosal fibroids were successfully removed with a minimal hysteroscopic fluid deficit. Patient tolerated the procedure well. <h3>Conclusion</h3> Multiple submucosal fibroids were safely and efficiently removed using the strategies above. A purse-string suture on the cervix prevents leakage of hysteroscopic fluid while maintaining uterine distension. Large fibroids were enucleated and removed intact through the dilated cervix.