Uterine Artery Clipping at the Level of the Ureteric Tunnel for Reduction of Blood Flow

Abstract

Study Objective Though cervical myomas comprise only 5% of total uterine myomas, they present unique surgical challenge due to proximity to the uterine vessels and ureters. We aim to highlight an approach to robotic-assisted hysterectomy with a large cervical fibroid, with minimal blood loss and clear visualization of the displaced anatomy. Design Video Case Presentation. Setting A robotic-assisted hysterectomy (RAH) was performed under general anesthesia in dorsal lithotomy position at a university-affiliated hospital. Patients or Participants 41-year-old G0 with abnormal uterine bleeding in the setting of 5 × 4 × 5 cm subserosal fibroid of the left posterior cervix. The patient was pretreated with leuprolide acetate injections then letrozole to reduce the fibroid volume, however, no change in size was observed. The patient desired definitive management of the fibroid. Interventions Once in the operating room, a uterine manipulator could not be placed due to displacement of the cervix by the fibroid. Careful retroperitoneal dissection was performed to identify the uterine artery coursing over the ureter at the ureteric tunnel of Wertheim. Laparoscopic clips were applied to the uterine artery to decrease blood supply to the fibroid. After completion of the hysterectomy, the fibroid capsule was entered and myomectomy was completed, resulting in separation of the fibroid from the vagina. Measurements and Main Results Estimated blood loss was 50 cc. Final specimen were uterus, fallopian tubes, and cervix weighing 54 g and cervical fibroid weighing 99 g. The patient had an uncomplicated postoperative course and was discharged home on postoperative day 1. Conclusion This case demonstrates the use of minimally-invasive surgical approach to safely complete a hysterectomy in the context of a large, cervical myoma. Our video demonstrates improved hemostasis and visualization of the ureters throughout the case due to placement of vessel clips at the level of the ureteric tunnel. Though cervical myomas comprise only 5% of total uterine myomas, they present unique surgical challenge due to proximity to the uterine vessels and ureters. We aim to highlight an approach to robotic-assisted hysterectomy with a large cervical fibroid, with minimal blood loss and clear visualization of the displaced anatomy. Video Case Presentation. A robotic-assisted hysterectomy (RAH) was performed under general anesthesia in dorsal lithotomy position at a university-affiliated hospital. 41-year-old G0 with abnormal uterine bleeding in the setting of 5 × 4 × 5 cm subserosal fibroid of the left posterior cervix. The patient was pretreated with leuprolide acetate injections then letrozole to reduce the fibroid volume, however, no change in size was observed. The patient desired definitive management of the fibroid. Once in the operating room, a uterine manipulator could not be placed due to displacement of the cervix by the fibroid. Careful retroperitoneal dissection was performed to identify the uterine artery coursing over the ureter at the ureteric tunnel of Wertheim. Laparoscopic clips were applied to the uterine artery to decrease blood supply to the fibroid. After completion of the hysterectomy, the fibroid capsule was entered and myomectomy was completed, resulting in separation of the fibroid from the vagina. Estimated blood loss was 50 cc. Final specimen were uterus, fallopian tubes, and cervix weighing 54 g and cervical fibroid weighing 99 g. The patient had an uncomplicated postoperative course and was discharged home on postoperative day 1. This case demonstrates the use of minimally-invasive surgical approach to safely complete a hysterectomy in the context of a large, cervical myoma. Our video demonstrates improved hemostasis and visualization of the ureters throughout the case due to placement of vessel clips at the level of the ureteric tunnel.