Large Cervical Fibroid Research Articles

Technical Considerations for Total Laparoscopic Hysterectomy for Large Cervical Fibroid Precluding Placement of Uterine Manipulator

Technical Considerations for Total Laparoscopic Hysterectomy for Large Cervical Fibroid Precluding Placement of Uterine Manipulator

A Case of Large Cervical Leiomyoma

Uterine Leiomyoma or Myoma or commonly favorite named Fibroid is a most common entity of genital organ tumor. It isalmost benign tumor of smooth muscle origin where smooth muscle fiber and fibrous connective tissue intermingled togetheroften found in uterus. Although it is a disease of nulliparous but in perspective of our country it diagnosed in patient's havingone or two child because of early marrital status. Tumor varies in number 1-200 and also varies different clinical features andseverity depending site of presentation. Leiomyoma is generally slowly progressive disease but sometimes it grows veryrapidly. With the advent of Ultrasonography it is incidentally diagnosed often with asymptomatic cases. UsuallyUltrasonography is the single most predictor of investigation1 from very early cases although MRI is helpful. Asymptomatic large Fibroid present with various unusual symptoms like pressure symptom of surrounding structure or feelingof heaviness of lower abdomen or fullness of abdomen. Large cervical Fibroid is a uncommon presentation with mainly urinarydifficulties where patients chief complaints is frequent micturation and incomplete voiding of urine without significantmenstrual abnormalities. The described cases for urinary complain patient consulted with urologist and referred as a largecervical Fibroid diagnosed by sonography. This article illustrates a case of 34 years old lady present with frequent micturationand incomplete voiding of urine that developed last 5-6 months duration. Total abdominal hysterectomy performed,histologically the specimen showed benign uterine leiomyoma. Post operative circumstance uneventful evaluation occur andpatient back to home with normal duration hospital stay.

Cervical Fibroids: A Surgical Challenge

ABSTRACT Leiomyomas are the most common benign tumors affecting the female reproductive tract and constitute around 18–20% of all the uterine pathologies that are seen in women of reproductive age group. Based on their location in the uterus, fibroids can be uterine, cervical, and ligamentary, of which the cervical fibroids are the rarest and make up only around 2–2.5% of the total incidence of fibroids. Large cervical fibroids generally give a typical appearance of “Lantern on St. Paul’s dome,” where the small size uterus sits on top of the cervical fibroid mimicking the lantern on the dome of the famous St. Paul’s Cathedral of Russia. We report here a case series of cervical fibroids who reported to the gynecology OPD of our institute. The first patient was a 41-year-old lady who presented with complaints of heavy menstrual bleeding for the last 2 years. Clinical findings as well as imaging confirmed a 24-week size large cervical fibroid along with surprise element in form of double ureters on right side on intravenous urogram(IVU). Our second patient was a peri-menopausal lady with heavy menstrual bleeding(HMB)for 2 months and cervical fibroid of 16-week size gravid uterus on examination. The third patient was a 37-year-old lady with heavy menstrual bleeding with pressure symptoms in the form of retention of urine. Clinically, a 16-week size cervical fibroid was present which after surgery revealed STUMP on histopathology. All patients were managed surgically with uneventful postoperative recovery.

Cervical Fibroids - Key Surgical Steps

<h3>Study Objective</h3> To review critical steps during robotic assisted total laparoscopic hysterectomy in patients with large cervical fibroids, focusing on tips for safely performing ureterolysis, isolation of uterine vasculature, and colpotomy. <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> Surgery is the primary therapy for cervical leiomyomas, which account for 0.6-2% of uterine fibroids. Cervical fibroids significantly alter anatomy, making a minimally invasive approach prohibitive to many providers. The size and location of the fibroid can cause alterations in ureter course and uterine vasculature, inability to use a uterine manipulator, and deformation of the colpotomy. <h3>Patients or Participants</h3> The first case depicts a patient with a 7.9-cm, midline, cervical fibroid. She received preoperative Leuprolide twice, resulting in a decrease in maximum diameter to 5.5 cm intra-operatively. The second case demonstrates a patient with a 13-cm cervical fibroid on imaging, noted to be at least 15 cm intra-operatively, causing bilateral hydroureters and hydronephrosis. <h3>Interventions</h3> This video demonstrates how to navigate the main challenges afforded by cervical fibroids when performing robotic hysterectomy. It includes how to create the space needed for ureterolysis and demonstrates using the ureter as a tool for navigation in the altered retroperitoneum. It highlights the importance of ligating the uterine arteries at their origin and reflecting the uterine arteries from medial to lateral. Finally, it reviews tips for completing a colpotomy using an end-to-end anastomosis (EEA) sizer as a guide and dynamic tool. <h3>Measurements and Main Results</h3> Both patients did well postoperatively with resolution of their symptoms. The second case had complete resolution of hydroureters and hydronephrosis. <h3>Conclusion</h3> Surgery is the primary therapy for cervical leiomyomas. A minimally invasive approach has proven benefits over open surgery but poses challenges due to distortion of normal anatomy. In the appropriate patient with a large cervical fibroid, robotic and laparoscopic hysterectomy can safely be performed by a skilled minimally invasive surgeon.

Navigating Cervical Fibroids during Laparoscopic Hysterectomy: Essential Tips and Tricks

<h3>Study Objective</h3> To review three key strategies to safely navigate cervical fibroids when performing a laparoscopic hysterectomy. <h3>Design</h3> Case series of two patients undergoing total laparoscopic hysterectomy (TLH) for abnormal uterine bleeding in the setting of large cervical fibroids. <h3>Setting</h3> Both patients underwent their planned surgeries at a large-volume county hospital. Video footage was obtained during these procedures. <h3>Patients or Participants</h3> Two women who had completed childbearing and desired definitive surgical management for abnormal uterine bleeding underwent TLH. The first patient's cervical fibroid was 6.5cm in size, and the second patient's cervical fibroid was 8cm in size, confirmed on both pelvic exam and pre-operative pelvic MRI imaging. Neither patient had a significant past medical or surgical history. <h3>Interventions</h3> Total laparoscopic hysterectomy for a patient with a large cervical fibroid can be completed safely using three key strategies: 1. Ureteral identification, including ureterolysis if necessary and consideration of prophylactic ureteral catheter placement 2. Ligation of the uterine artery at its origin to minimize risk of blood loss 3. Delineation of the cervicovaginal junction using a Breisky-Navratil retractor to safely perform the colpotomy <h3>Measurements and Main Results</h3> The two presented cases demonstrate successful incorporation of the above techniques and ultimately safe completion of the laparoscopic hysterectomy for both patients. <h3>Conclusion</h3> Cervical fibroids are rare, however when present, can pose unique challenges to the gynecologic surgeon when performing a laparoscopic hysterectomy. Here we demonstrate three reproducible techniques for minimizing injury to adjacent organs and minimizing intraoperative blood loss, allowing the surgeon to safely navigate the difficulties presented by the cervical fibroid and maintain a minimally invasive approach.

Five tips and tricks for approaching large cervical fibroids with a broad ligament component

This video will demonstrate five tips and tricks for robotic excision of cervical fibroids with a broad ligament component by utilizing two case examples. Tip number 1 is a thorough physical exam including speculum and bimanual exams. In our first case the physical exam reveals an obscured cervix by the large cervical fibroid and our second case reveals a markedly deviated cervix. These findings help the surgeon anticipate which uterine manipulator might be helpful during the case. Tip number 2 is a systematic review of MRI imaging. T2 weighted imaging in three planes is ideal for assessing fibroids size, location, and relationship to the endometrium, lower uterine segment, and lateral structures. Tip number 3 is to access the pararectal space and to demonstrate techniques of ureterolysis. In both cases, the round ligament is transected and the incision extended parallel to the infundibulopelvic ligament. The ureter is identified on the medial leaf of the broad ligament. Tip number 4 is to demonstrate skeletonization and occlusion of the uterine artery. The uterine artery is identified and skeletonized, either at its origin or crossing over the ureter. The borders of the pararectal space are reviewed and placement of a hem-o-lock clip is demonstrated. This technique allows for vascular control and safe resection of a large fibroid despite its proximity to the uterine artery and ureter. Tip number 5 is to show techniques for complete excision of large cervical fibroids. Important techniques employed include cephalad traction of the fibroid for good visualization and circumferential dissection. These five tips and tricks can be utilized to safely approach robotic excision of cervical fibroids with a broad ligament component as seen in our two case examples

Resurgence of classical caesarean section in current obstetric practice- A case series

Although, the incidence of placenta accreta spectrum (PAS) and large fibroids is rare but still these cases contributes to a large number of maternal morbidity and mortality. Major obstetric hemorrhage is one the dreadful complication of these types of cases and thus early diagnosis and intervention in such cases helps the physician to minimize the risk to mother and the fetus. Also, current widespread use of ultrasound has helped us to manage these cases judiciously, predict and prevent life threatening obstetric hemorrhage. Here we present three complicated obstetric cases of placenta accreta, large lower segment uterine fibroid and large cervical fibroid which necessitated classical cesarean sections (CCS) thus emphasizing prowess in CCS in modern obstetric era. High index of suspicion, Multidisciplinary approach alongwith expert surgical personnel should be available in high risks cases like placenta accreta syndrome and large fibroids in pregnancy.

Tips and Tricks: Laparoscopic Hysterectomy with Large Cervical Fibroid

Study Objective This video describes various techniques to successfully perform a hysterectomy with a large cervical fibroid in a minimally invasive fashion. Design Case studies of two patients with large cervical fibroids who underwent definitive surgical management with total laparoscopic hysterectomy (TLH). Setting The video clips were taken in the operating room during planned procedures for two separate cases of patients undergoing TLH with cervical fibroids. Both patients were positioned in dorsal lithotomy with arms tucked. Patients or Participants The two patients each had 8-9 cm symptomatic cervical fibroids for which they desired definitive surgical management with hysterectomy. Their exams differed in length and accessibility of the cervix and in BMIs, as one patient had a shortened cervix with BMI of 28 and the other had an effaced and deviated cervix and BMI of 32. Interventions A set of techniques were employed to mitigate the challenge of TLH with a large cervical fibroid. This included pretreatment with Lupron, ureteral stent placement, ligation of uterine arteries at their origin, and different methods for completing colpotomy. Measurements and Main Results The cases exemplified how these techniques can be successful and how to use alternate approaches when unsuccessful. Both hysterectomies were successfully completed laparoscopically. Conclusion Cervical fibroids can present a challenge to accomplishing hysterectomy in a minimally invasive fashion. Successful laparoscopic hysterectomy can be performed with use of various techniques to reduce risk of bleeding and injury to nearby structures. More research is needed to help determine predictors for successful and unsuccessful applications of such techniques. This video describes various techniques to successfully perform a hysterectomy with a large cervical fibroid in a minimally invasive fashion. Case studies of two patients with large cervical fibroids who underwent definitive surgical management with total laparoscopic hysterectomy (TLH). The video clips were taken in the operating room during planned procedures for two separate cases of patients undergoing TLH with cervical fibroids. Both patients were positioned in dorsal lithotomy with arms tucked. The two patients each had 8-9 cm symptomatic cervical fibroids for which they desired definitive surgical management with hysterectomy. Their exams differed in length and accessibility of the cervix and in BMIs, as one patient had a shortened cervix with BMI of 28 and the other had an effaced and deviated cervix and BMI of 32. A set of techniques were employed to mitigate the challenge of TLH with a large cervical fibroid. This included pretreatment with Lupron, ureteral stent placement, ligation of uterine arteries at their origin, and different methods for completing colpotomy. The cases exemplified how these techniques can be successful and how to use alternate approaches when unsuccessful. Both hysterectomies were successfully completed laparoscopically. Cervical fibroids can present a challenge to accomplishing hysterectomy in a minimally invasive fashion. Successful laparoscopic hysterectomy can be performed with use of various techniques to reduce risk of bleeding and injury to nearby structures. More research is needed to help determine predictors for successful and unsuccessful applications of such techniques.

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

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.

Surgical Approach to Laparoscopic Hysterectomy for a Large Cervical Fibroid

<h3>Study Objective</h3> To demonstrate surgical techniques aimed at successfully navigating the anatomic distortion caused by cervical fibroids during hysterectomy. <h3>Design</h3> N/A. <h3>Setting</h3> The patient was placed in dorsal lithotomy position in steep Trendelenburg to aid in performance of pelvic laparoscopy. Insufflation was carried out to 15mmHg. A primary 10mm umbilical trocar was used for the camera and three additional assist ports were placed. <h3>Patients or Participants</h3> The patient is a 37-year-old G1P1001 who presented with heavy bleeding and cramping. Work-up revealed a 6cm cervical fibroid. The patient did not desire future fertility and elected to undergo laparoscopic hysterectomy. The patient was given three months of a GnRH agonist to control bleeding and improve pre-operative hemoglobin. <h3>Interventions</h3> Total laparoscopic hysterectomy with bilateral ligation of the uterine artery at its origin from the hypogastric artery, bilateral salpingectomy, bilateral ureterolysis, cystoscopy with placement of ureteral stents. <h3>Measurements and Main Results</h3> Uncomplicated surgery with same-day discharge followed by uneventful post-operative recovery. <h3>Conclusion</h3> Large cervical fibroids present many surgical challenges, but laparoscopic hysterectomy can be safely and efficiently performed using the reproducible techniques outlined in this video.

Caesarean myomectomy of a large cervical fibroid.

Caesarean myomectomy of a large cervical fibroid.

Cervical fibroid in pregnancy - Case report and review of literature

Cervical fibroid in pregnancy - Case report and review of literature - IJOGR- Print ISSN No: - 2394-2746 Online ISSN No:- 2394-2754 Article DOI No:- 10.18231/j.ijogr.2019.117, Indian Journal of Obstetrics and Gynecology Research-Indian J Obstet Gynecol Res

Successful Return of Regular Menstrual Flow After Removal of A Huge Cervical Fibroid: A Case Report

Fibroids are the commonest benign neoplasm of the uterus and have long been implicated as a cause of complication during pregnancy and delivery. Fibroids arising from uterine cervix constitute only less than 2% of all fibroids and a very large cervical fibroid is even rarer1·2·3. This is case report of pregnancy with a huge cervical fibroid that necessitated caesarean section delivery. This unusually large fibroid (20 x 17 x 16 cm) was grown from the cervix that pushed up the uterine body upward. During initial caesarean operation the surgical team could not ascertain about the origin of the mass and closed the abdomen without remony the man. Subsequent laparotomy three months after caesarean section finally confirmed the diagnosis of the huge cervical fibroid. It was dissected out from the surrounding adhesion followed by end-to-end anastomosis of the gap between uterus and cervix. The postoperative period was uneventful with smooth recovery. The patient was followed up couple of times after discharge and reported to be well with return of her normal menstrual and reproductive function.&#x0D; Journal of Surgical Sciences (2013) Vol. 17 (1) : 58-61

An Unusual Presentation of a Large Cervical Fibroid—Case Report

Uterine fibroids are the commonest pelvic tumors of reproductive-age women, while the incidence of cervical fibroid is only 1–2%. We noted the patient’s clinical history, examination findings, diagnostic tools, management, and outcome. We report a 53-year-old parous lady who was initially diagnosed with malignant ovarian tumor on the basis of clinical manifestations and imaging findings. Intraoperatively, it turned out to be a large cervical fibroid. Total abdominal hysterectomy was performed without any intraoperative complications. Anticipation of complications and preventive measures during surgery are the key of successful outcome in large cervical fibroids. To avoid ureteric injury, preoperative stenting, intra-operative delineation of ureters, and dissection inside the fibroid capsule are the best principles.

Surgical Approach to a Large Cervical Fibroid

<h3>Video Objective</h3> The objective of this video is to outline a unique approach to removal of a large intracervical fibroid during hysterectomy. <h3>Setting</h3> The patient is a 49 year-old para 3 who presented with pelvic pain, pressure and increased abdominal girth. She was found to have a 20 week size uterus with a large intracervical fibroid on exam. Her cervix was dilated to 4 cm and effaced on exam and the fibroid was palpable. MRI demonstrated a large multi-fibroid uterus, with a dominant 10 centimeter cervical fibroid and a dominant 9 centimeter broad ligament fibroid. She desired definitive management of her symptoms. <h3>Interventions</h3> After extensive surgical planning, a hysterectomy was performed in a three-staged approach. Stage one included dissection of the broad ligament fibroid and ligation of the uterine arteries. Stage 2 of the procedure involved a vaginal myomectomy, in which the cervical fibroid was dissected after use of Duhrssen's incisions on the cervix. The uterine manipulator was then secured using 0 prolene suture. In the last stage of the procedure, the hysterectomy was completed laparoscopically and the entire specimen removed vaginally. The patient had an uncomplicated postoperative course and surgical pathology was consistent with benign leiomyoma. <h3>Conclusion</h3> In this video we outline one unique and feasible approach to hysterectomy when there is a large cervical fibroid. When considering surgical approaches, it is important to remember that there may be distortion of the usual anatomy due to fibroids. Through use of Duhrssen's incisions, we were able to use an obstetrical surgical technique to aide in the removal of a large intracervical fibroid.

Cervical angiomyxoma: a rare benign and recurrent cervical mass simulating common pathologies

We aimed to present a rare case of uterine cervix angiomyxoma in a 39 years old female. Patient presented with vaginal mass and abnormal vaginal bleeding. Properative diangosis was large cervical polyp versus cervical fibroid. Total hystrectomy was done and specimen was sent for histopathology. The suspicious mass revealed spindle cell in myxoid stroma compatible with angiomyxoma. Uterine cervix angiomyxoma is a rare soft tissue tumor with few reported cases in the literature.

Management of Giant Cervical Fibroid By “Hybrid Technique”

Cervical fibroids are a rarity as compared to fibroids arising from other parts of the uterus. These rare fibroids account for 1-2% of all fibroids. They arise from supravaginal or vaginal portion of cervix. They can be either anterior, posterior, central or lateral. Our case is unique in many ways, firstly the huge size of the tumor, its rapid growth and its management laparoscopically. We report a case of 47-year-old female who presented with complain of pain abdomen and menorrhagia since last 10 years. Abdominal examination revealed a huge firm mass corresponding to 34 weeks size gravid uterus with well defined margins. The lower pole of the mass could not be reached and mobility was not there due to its size. MRI revealed a large fibroid arising from the posterior wall of the cervix displacing the uterus to the left and anteriorly. After necessary investigations, arranging adequate blood and written informed consents, patient was taken up for laparoscopic hysterectomy. Intraoperative findings were of a large cervical fibroid seen extending from depth of the pelvis uptil four inches below xiphisternum and abutting right lateral wall. Uterus was deviated to the left side by the tumor. Left tube and ovary were normal looking, but right tube was stretched over the tumor along with the ovary. Hysterectomy was done including the separation of the fibroid from all its attachments, but in view of large size of the mass and high suspicion of sarcomatous changes within the tumor, laparotomy was done to deliver out the tumor with uterus and bilateral adnexa. The operative time was around 3 hours and estimated blood loss during the surgery was around 500ml. Patient was given 2 units of PCV and 2 units of FFP’s. Her postoperative period was uneventful. Histopathology report was in conformity with that of a cervical fibroid. To conclude, management of such cases laparoscopically helps in decreasing blood loss during surgery to a large extent and helps in decreasing patient morbidity in the hand of experienced endoscopist team.

Challenges of a Large Cervical Fibroid in Pregnancy

Thisis a case report of a 31-year old woman who presented with an incidental finding of a large cervical fibroid in pregnancy. She was closely monitored antenatally. The cervical fibroid increased in size as the pregnancy progressed. Magnetic resonance imaging of the pelvis suggested low risk of malignancy despite the rapid growth of the cervical fibroid. She was managed conservatively throughout her pregnancy and subsequently underwent an elective caesarean section to deliver a baby girl. Postnatally, the cervical fibroid shrunk minimally and the patient underwent a laparotomy myomectomy 7 months later. The surgery was complicated by severe haemorrhage, which resulted in a total hysterectomy

Huge cervical fibroid

Fibroids in the cervical region of the uterus are uncommon because of the rarity of smooth muscles. The aim of the study was to present this rare finding in our centre and to show our management and the challenges encountered. We present a 45-year-old multipara who before the presentation had 6-year history of abnormal vaginal bleeding and was previously managed in a peripheral hospital. Physical examination suggested a large cervical fibroid and a hydronephrosis on the right displayed on intravenous urogram. She had total abdominal hysterectomy with the urologist who repaired an inadvertent ureteric injury and inserted a stent. It was removed after 6 weeks, and she was discharged with no further complications. Management of such patients should involve other disciplines after careful evaluation has been carried out.

Large cervical fibroid mimicking an ovarian tumour

Leiomyomas are the commonest uterine and pelvic tumours. The usual anatomical location is the body of the uterus. Cervical leiomyomas are uncommon and presentation as a huge abdominal mass is rare. We report a case of a 45-year old female who presented with abdominal distension and weight loss for one year. Abdominal examination revealed a huge mass of 40 week size pregnant uterus filling the whole abdomen with restricted mobility, non tender and solid consistency mimicking an ovarian tumour. On ultrasound this was a solid mass with a cystic component. There was a large cervical fibroid visualized on laparotomy which was successfully removed. Histopathological examination showed a cervical fibroid with hyaline and cystic degeneration. The patient had an uneventful postoperative recovery. DOI: http://dx.doi.org/10.4038/sljog.v33i1.4000 SLJOG 2011; 33(1): 26-27