Abstract
Introduction
The pedunculated fibroid is classically managed through vaginal myomectomy. However, vaginal myomectomy cannot be safely and easily performed in all cases. We reviewed three cases of prolapsed pedunculated submucosal fibroids, each with a specific surgical difficulty.
Presentation of cases
The first case had a prolapsed pedunculated uterine fibroid in pregnancy and underwent fibroid extirpation during an emergency cesarean section through the lower uterine segment incision. The second case was a nulliparous woman with recurrent abnormal uterine bleeding due to a giant prolapsed pedunculated uterine fibroid who underwent laparotomy fibroid extirpation through posterior colpotomy, preserving the uterus. The third case had a prolapsed pedunculated uterine fibroid in perimenopause with multiple fibroids and underwent fibroid stalk excision through an isthmic incision to facilitate a safe laparotomy hysterectomy procedure.
Discussion
Vaginal removal has become the standard surgical method for prolapsed pedunculated submucous fibroids. However, some possible consequences of vaginal myomectomy include severe stalk bleeding, infection, and uterus inversion induced by excessive traction. Therefore, specific approaches are needed in some circumstances.
Conclusion
Customised surgical approaches provided safe and efficient access to the prolapsed pedunculated fibroid stalk during myomectomy or hysterectomy.
Keywords: Hysterectomy, Myomectomy, Surgical technique, Prolapsed pedunculated fibroids
Highlights
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We present 3 prolapsed-pedunculated submucosal fibroids with special circumstance requiring specific surgical approach.
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First case underwent fibroid extirpation during cesarean section through lower uterine segment incision.
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Second case underwent fibroid extirpation through laparotomy and posterior colpotomy.
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Third case underwent laparotomy hysterectomy facilitated by fibroid extirpation through istmical incision.
1. Introduction
The pedunculated fibroid is a leiomyoma attached by a stalk to its progenitor myometrium [1]. Submucosal leiomyomas account for approximately 15 %–20 % of all leiomyomas [2]. The actual prevalence of prolapsed pedunculated submucosal myoma remains unknown. However, the estimated prevalence of leiomyomas was 2.5 % among patients who underwent surgery [2].
The simple surgical management of uterine fibroids involves twisting the fibroid's stalk vaginally or vaginal myomectomy. However, this classical surgical technique is unsuitable in cases with a narrow vaginal space or limited access. This case series reviews the surgical approaches used in various cases of pedunculated submucosal fibroids, each with a specific surgical difficulty. Understanding the various surgical approaches in this case series will benefit clinicians who manage complicated pedunculated submucous fibroids and those who explore alternative safe surgical techniques. This case series has been reported according to the PROCESS 2020 [3] and SCARE 2018 [4] guidelines.
2. Presentation of cases
2.1. Case one
A 30-year-old woman (G (Gravida) 1, 30 weeks of gestational age, single foetus) attended the emergency room with the chief complaint that her water broke one day before admission. The patient had already been diagnosed with pedunculated uterine fibroid for two years.
She admitted a history of chronic vaginal spotting and presented with anaemia (haemoglobin [Hb] level = 7.6 g/dL). On in-speculum evaluation, we found a 7 cm diameter mass with a smooth surface, suggesting a prolapsed pedunculated cervical fibroid. On vaginal touche, we found a palpated solid-supple mass in the vagina with a 3 cm diameter originating from the posterior cervical lips (6 o'clock).
Ultrasound examination found a baby estimated to weigh 900 g in the breech position, the placenta in the fundal area, no retroplacental haemorrhage, and oligohydramnios (amniotic fluid index: 3.5). In addition, a 7 cm hypoechoic mass was found in the vagina with a stalk originating from the posterior cervical lips (feeding artery was positive), corresponding to a prolapsed-pedunculated cervical fibroid (Fig. 1).
Fig. 1.
Examination of the first case. (a) Speculum examination: solid-supple mass with a smooth surface and amniotic fluid pooling. (b) Ultrasound examination: pedunculated cervical fibroid with feeding artery through the birth canal.
She underwent an emergency cesarean section due to non-reassuring fetal status (pathological cardiotocography). We made a low transverse incision on the lower uterine segment and delivered a baby boy (900 g). We placed four foerster clamps at the four edges of the lower uterine segment incision (upper left, upper right, lower left, and lower right). Then, we performed a hemostatic suture using polyglactin No. 1 to replace those haemostatic clamps. Some bleeding from the lower uterine segment incisions was clamped using a forester clamp. The placenta was delivered whole. The operator reached the cervical fibroid stalk by palpation through the opened lower uterine segment. The stalk was encircled and tied up with polyglactin No 1 before being pulled cranially to expose its base at the cervical lips (6 o'clock) through the open lower uterine segment incision. The stalk was clamped, cut, and the stalk base was sutured using polyglactin No 1 (Fig. 2), then the cut fibroid was taken out through the vaginal canal after surgery.
Fig. 2.
Intraoperative view of the first case after the baby and placenta had been delivered. (a) The stalk of the pedunculated fibroid was exposed through a cesarean section incision; it was 3 cm thick. (b) The stalk was clamped, cut, and sutured before the cut fibroid was taken out through the vagina after surgery.
There was no significant additional bleeding from the fibroid stalk. We extirpated the 6 × 7 cm cervical fibroid through the vaginal canal and sent it for histopathologic evaluation (Fig. 3). The patient went home three days after the operation. Histopathology confirmed the fibroid as submucous leiomyoma.
Fig. 3.
Images of the specimen from the first case. (a) The fibroid was 7 cm in diameter. (b) The incised surgical specimen.
2.2. Case two
A 31-year-old woman (P0A0, no history of sexual intercourse) was referred to our emergency room due to recurrent heavy menstrual bleeding (the last bleeding persisted for two weeks). Her menstrual period was regular, usually seven days, with 6–7 pads/day and dysmenorrhea (Visual Analogue Scale [VAS]: 5–6). On her last period, she had massive menstrual bleeding (three diapers/day) with dysmenorrhea (VAS: 7). She has already been diagnosed with prolapsed pedunculated submucosal uterine fibroids in a gynaecology outpatient clinic and planned for elective surgery. She had a laparotomic left cystectomy three years ago in another hospital (the histopathologic data was unavailable).
On arrival, we found the patient was anaemic with a Hb level of 4.5 g/dL (post-packed red blood cell transfusion at referral hospital) with stable haemodynamics. On lower abdomen examination, we found a solid mobile mass as high as navel. The speculum evaluation found active bleeding, with a bulky 13 cm diameter mass with a smooth surface filling the vaginal cavity.
On ultrasound evaluation, we found a 21.9 × 13.2 cm hypo-hyperechoic mass on the cervical canal with a feeding artery and clearly defined borders originating from a pedunculated submucosal fibroid. The stalk of the fibroid was in the uterine fundal (Fig. 4).
Fig. 4.
Ultrasound assessment of the second case. (a) Abdominal ultrasound found a fibroid prolapsed through the cervix. (b) Transperineal ultrasound found that the fibroid was protruding into the vagina.
The obstetrics and gynaecology doctor performed a median-incision laparotomy around the previous laparotomy scar. The uterus was exteriorised. On exploration, we found an enlarged uterus with a smooth surface size of 15 cm and a posterior uterine mass bulging into the posterior vagina; both ovaries were normal (the left ovary had a cystectomy). We performed an 8 cm transverse posterior colpotomy (Fig. 5). We identified the 21 × 17 cm prolapsed pedunculated submucous fibroid and evaluated the fibroid stalk originating from the anterior uterine corpus (Fig. 6). We performed fibroid extirpation before removing the fibroid through the uterine cavity via the posterior colpotomy. The fibroid's implantation site was repaired by continuous suture with Monosyn 3.0, and the posterior vagina was sutured continuously in two layers using polyglycolic acid (PGA) No.1 (Fig. 7).
Fig. 5.
Intraoperative view of the second case. (a) Bulging of the posterior vagina. (b) Posterior colpotomy.
Fig. 6.
Intraoperative view of the second case. (a) A fibroid was identified in the fundal area. (b) The fibroid stalk was cut.
Fig. 7.
The specimen from the second case. (a) The fibroid implantation site was sutured with a continuous suture. (b) The final view of the repaired stalk implantation site. (c) The removed fibroid.
The patient was discharged three days after the operation. The surgical wound was good. The histopathology confirmed a leiomyoma.
2.3. Case three
A 47-year-old woman (P2A0) was referred to our Gynaecology Outpatient Clinic for a protruded vaginal mass (suspected pedunculated submucous fibroid). She had prolonged menstruation since one year before admission (10–15 days, 7–8 pads/day, mild dysmenorrhea). On speculum examination, we found a solid vaginal mass of 5 × 4 × 4 cm with a smooth surface and 1.5 cm intracavitary-originating stalk.
On ultrasound examination, we found a 5.08 × 3.28 cm solid hypoechoic mass with distinct borders protruding through the cervix and reaching the vagina with a pedicle originating from the uterine cavity. We also found a 3.6 × 2.8 cm hypohyperechoic mass in the fundal area, corresponding to a subserous uterine fibroid (Fig. 8).
Fig. 8.
Transvaginal ultrasound appearance of the third case. (a) A hypoechoic mass with clear borders protruded into the vaginal canal, corresponding to a prolapsed pedunculated submucosal fibroid. (b) The stalk originated from the fundal area. (c) Multiple uterine fibroids were visible.
The patient was a 47-year-old woman with heavy menstrual bleeding, dysmenorrhea, multiple uterine fibroids, and not desiring further pregnancy. She underwent an elective total hysterectomy. We performed a Pfannenstiel incision and found a 3 cm subserous uterine fibroid on the fundal part, and submucous uterine fibroids with a stalk originating from the posterior uterine wall, with an enlarged isthmus area (7 cm diameter; Fig. 9). Both tubes and the left ovary were within normal limits. A 2 cm cyst was seen on the right ovary and adhered to the right tube. While performing adhesiolysis, chocolate-coloured fluid leaked from the right endometrioma (it was cystectomised later). We clamped and cut both round ligaments, the true ovarian ligament, and the tube, and then sutured them using PGA No. 1. We continued to clamp, cut, and suture the ascending part of the vasa uterine. On the isthmus part, the fibroid bulge might shift the anatomical location of the ureter towards the uterine vessel. To avoid ureter injury and enable a more straightforward surgery, we performed a vertical incision on the isthmus and identified the submucous myoma pedicle. The pedicle was cut, the myoma was pushed into the vagina, leaving no bulge in the isthmus, and revised the ureter-uterine vessel space. We continued the hysterectomy procedure by clamping, cutting, and ligating the uterine vessels, then made a colpotomy on the cervicovaginal junction. The vaginal stump and sacrouterine ligament were sutured with PGA No. 1 before the cut uterine fibroid was taken out through the vagina after surgery (Fig. 10).
Fig. 9.
Intraoperative view of the third case. A Pfannenstiel incision was made to see the submucosal fibroid in the fundal area.
Fig. 10.
Intraoperative view of the third case. (a) During the hysterectomy, a vertical incision was made in the isthmus, and the pedicle of a pedunculated submucosal fibroid was identified. (b) The pedicle was cut and pushed through the vagina. (c) The removed specimens.
The patient was stable and sent home two days after surgery. The histopathology confirmed multiple leiomyomas and a right endometriosis cyst (Table 1).
Table 1.
Cases resume.
| No | Case illustration | Age | Parity | Case characteristics | Case challenges | Specific surgical approach |
|---|---|---|---|---|---|---|
| 1 |  |
30 years old | G1P0 | -Pregnant, underwent cesarean section -Pedunculated submucosal fibroid since before married |
-Pedunculated fibroid covered the birth canal | Incision of the fibroid stalk through c-section access and removal through the vagina |
| 3 |  |
31 years old | P0A0 | -Nulliparous -Giant prolapsed pedunculated submucosal fibroid |
-No history of sexual intercourse -Giant fibroid could not be evacuated vaginally (to prevent the hymenal ring from being torn) |
Laparotomy, extirpation of fibroid through posterior colpotomy |
| 2 |  |
47 years old | P2A0 | -Perimenopause woman -Multiple uterine fibroids -Right endometriosis cyst |
-Difficult vaginal access -Istmical anatomy distorted by the fibroid, high risk of ureteric injury |
Laparotomy, hysterotomy, and fibroid extirpation to facilitate safe hysterectomy |
3. Discussion
Our three patients had a history of abnormal uterine bleeding, anaemia, and vaginal mass. On physical examination, the three cases had a pedunculated chewy-solid mass with a smooth surface. On ultrasound evaluation, the three cases also suggested a prolapsed pedunculated submucous fibroid with a stalk originating in the cervix and the fundal cavity.
Vaginal removal has become the classical surgical approach for prolapsed pedunculated submucous fibroids [1]. Vaginal myomectomy offered a safe and straightforward procedure with a short hospital stay and minimal morbidity. However, some likely complications in vaginal myomectomy are excessive haemorrhage from the stalk, infection, and uterine inversion caused by excessive traction [2]. However, the abdominal approach could be considered in cases with a large and high-up fibroid stalk, inadequate vaginal surgical space, or needing a hysterectomy.
Fibroids are found in 3.2 % of pregnancies [5]. Others have reported that the prevalence of fibroids during pregnancy was 0.0865 %, of which two cases were pedunculated fibroids with postpartum haemorrhage [6]. A 2018 case series by Singh reported that fibroids in pregnancy increase the risk of preterm labour, anaemia, postpartum haemorrhage, and the need for cesarean delivery [7]. Among their 28 pregnant women with fibroids, 35.71 % had multiple fibroids with common intramural and subserous origins and sizes of 5–13 cm, and 39.29 % had anaemia [7]. Stout reported that pregnant women with fibroids had no increase in obstetric complications [5]. Sunderman reported no increase in fibroid prevalence among women with term delivery (10.2 %) and preterm delivery (10.3 %) [8]. However, a 2022 meta-analysis by Landman reported that fibroids increased the risk of preterm delivery [9].
Our first patient was nulliparity and had a mass of >5 cm (7 cm in diameter), and we considered them to have a narrow vaginal surgical space. Caglar previously reported that leiomyoma >5 cm could not be successfully managed vaginally and should be managed through hysterectomy [1]. In addition, since our patient had a stalk with a 3 cm diameter, the risk of difficulty in controlling the bleeding was higher. In contrast, abdominal access through a lower uterine segment incision would be more spacious and sufficient to reach the fibroid stalk base.
In 2017, Elgonaid reported a case of prolapsed submucous fibroid 35 days after vaginal delivery through manual extirpation under anaesthesia without significant bleeding [10]. However, we did not choose manual extirpation for our first case since it might lead to uncontrolled bleeding.
Our second case had a large fibroid with no history of sexual intercourse. The vaginal approach was difficult since we had insufficient space for the surgical procedure. In addition, she needed to keep her hymenal ring intact. Therefore, a laparotomy approach was chosen since it gave the best access and provided better stalk recognition through palpation, with more efficient extirpation of fibroid mass compared to the laparoscopic approach. We performed a posterior colpotomy to reach the fibroid stalk and extirpate the fibroid. No hysterotomy was performed to preserve the uterine wall to support the future pregnancy.
An alternative vaginal technique is a Duhrssen incision. Yoong reported 19 women with submucous and pedunculated fibroids who underwent a Duhrssen incision (median longitudinal incision on the anterior or posterior cervical lip), with bladder injury in one case [11]. However, their median fibroid diameter was 7 cm, while our case had a 21 × 17 cm fibroid. Another report vaginally managed a case with protruded cervical fibroids and elongated cervices with the Manchester procedure [12]. However, our case had normal cervical length and pedunculated subserous fibroids.
Our third case underwent a laparotomic hysterectomy. It has been reported that 40.9 % of uterine fibroids are extirpated by hysterectomy [10,11]. Another report managed a case with a massive prolapsed pedunculated submucous fibroid by hysterectomy through laparoscopic surgery. They first secured the uterine arteries through laparoscopy, then reduced the mass through vaginal extirpation of the 9 × 19 cm prolapsed pedunculated fibroid. Then, they continued the hysterectomy laparoscopically [13]. However, since our case had a large prolapsed fibroid mass around the isthmus with a stalk originating in the fundal area, the vaginal approach could not reach the fibroid stalk.
In considering vaginal myomectomy over hysterectomy for prolapsed pedunculated fibroids, Ayin reported that low parity, absence of coexisting fibroids, high fibroid volume on ultrasound, and severe anaemia were correlated with vaginal myomectomy success [2]. It was also possible to treat our second and third cases through laparoscopic surgery. However, due to limited resources, laparoscopy/minimally invasive surgery has a longer surgical queue than laparotomy in our centre. Therefore, laparotomy was chosen (especially since the second case was an emergency).
4. Conclusion
In conclusion, the surgical approach (vaginal or abdominal) and fibroid extirpation or hysterectomy is tailored to each anatomical difficulty and patient-centred clinical considerations. Several surgical approaches should be considered. In patients with limited vaginal access, an opportunistic abdominal approach (such as cesarean section) should be used. In patients with narrow, limited vaginal access (no sexual intercourse and nulliparous), a posterior colpotomy through abdominal access facilitates safer and easier surgery. In patients with limited vaginal access and anatomical distortion, cutting the fibroid stalk through hysterotomy facilitates safer and easier surgery.
Informed consent
Written informed consent was obtained from each patient to publish this case report and the included images. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.
Ethical approval
This is a case series, no ethical clearance needed.
Funding
None.
Author contribution
Gita Nurul Hidayah: Conceptualization, Investigation, Resource, Writing- Original draft, Writing-Review & editing
Achmad Kemal Harzif: Investigation, Writing-review & editing
Astri Noviani: Resource
Harry Prawiro Tantri: Investigation
Budi Iman Santoso: Writing-review & editing
Herbert Situmorang: Conceptualization, Investigation, Writing- Review & editing
Guarantor
Gita Nurul Hidayah.
Research registration number
Not applicable.
Conflict of interest statement
None.
Acknowledgements
Thank you Yuditya Purwosunu, MD, PhD for performing excellent ultrasound on case number 3.
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