Background: Submucosal fibroids account for approximately 15 - 20 percent of total fibroids. Rarely, they prolapse. Common size is 2 - 6 cm, because larger fibroids are unlikely to fit through the cervix. Larger fibroids are associated with significant bleeding and pose a surgical challenge. Case Presentation: We present a 38-year-old woman nulliparous with an intravaginal pedunculated fibroid, 12 cm in diameter. She presented with metrorrhagia and an intense malodorous vaginal discharge, irresponsive to oral therapy. The patient had a history of resectoscopic fibroid enucleation, 7 months earlier, followed by insertion of an (intra-uterine device) IUD. There was no uterine prolapse. Management involved bilateral uterine artery embolization, followed by hysteroscopic excision with rigid resectoscope. The fibroid was “delivered” transvaginally intact. The uterus was preserved. The IUD was partly buried within the mass. Blood loss was negligible. Patient recovery was quick and uneventful. At 6-months follow up, pelvic anatomy has been restored. Conclusion: Large pedunculated fibroids are very rare. Embolization of uterine arteries has proven a valuable tool in challenging gynecologic operations. In our case, not only it prevented massive bleeding during excision, but also allowed a fertility-sparing minimally invasive management.
References
[1]
Golan, A., Zachalka, N., Lurie, S., Sagiv, R. and Glezerman, M. (2005) Vaginal Removal of Prolapsed Pedunculated Submucous Myoma: A Short, Simple, and Definitive Procedure with Minimal Morbidity. Archives of Gynecology and Obstetrics, 271, 11-13. https://doi.org/10.1007/s00404-003-0590-x
[2]
Faivre, E., Surroca, M.M., Deffieux, X., Pages, F., Gervaise, A. and Fernandez, H. (2010) Vaginal Myomectomy: Literature Review. Journal of Minimally Invasive Gynecology, 17, 154-160. https://doi.org/10.1016/j.jmig.2009.12.007
[3]
Dicker, D., Feldberg, D., Dekel, A., Yeshaya, A., Samuel, N. and Goldman, J.A. (1986) The Management of Prolapsed Submucous Fibroids. Australian and New Zealand Journal of Obstetrics and Gynaecology, 26, 308-311.
https://doi.org/10.1111/j.1479-828X.1986.tb01595.x
[4]
Ben-Baruch, G., Schiff, E., Menashe, Y. and Menczer, J. (1988) Immediate and Late Outcome of Vaginal Myomectomy for Prolapsed Pedunculated Submucous Myoma. Obstetrics & Gynecology, 72, 858-861.
https://doi.org/10.1097/00006250-198812000-00009
[5]
Nkwabong, E. (2018) An Intramural Uterine Fibroid Became Submucosal in the Puerperium-Proposed Probable Mechanism: A Case Report. Journal of Medical Case Reports, 12, 88. https://doi.org/10.1186/s13256-018-1624-0
[6]
Newton, B.W. and Harmanli, O. (2016) Perplexing Presentation of Uterine Prolapse and a Prolapsed Pedunculated Leiomyoma. American Journal of Obstetrics & Gynecology, 215, 799.e1-799.e2. https://doi.org/10.1016/j.ajog.2016.08.028
[7]
Brito, L.G., Magnani, P.S., de Azevedo Trapp, A.E. and Sabino-de-Freitas, M.M. (2011) Giant Prolapsed Submucous Leiomyoma: A Surgical Challenge for Gynecologists. Clinical and Experimental Obstetrics and Gynecology, 38, 299-300.
[8]
da Silva, B.B., da Silva-Sampaio, J.P. and Lopes-Costa, P.V. (2018) Huge Prolapsed Pedunculated Necrotizing Submucosal Leiomyoma. Journal of Minimally Invasive Gynecology, 25, 1128-1129. https://doi.org/10.1016/j.jmig.2018.01.026
[9]
Kohi, M.P. and Spies, J.B. (2018) Updates on Uterine Artery Embolization. Seminars in Interventional Radiology, 35, 48-55.
https://doi.org/10.1055/s-0038-1636521
[10]
Keung, J.J., Spies, J.B. and Caridi, T.M. (2018) Uterine Artery Embolization: A Review of Current Concepts. Best Practice & Research Clinical Obstetrics & Gynaecology, 46, 66-73. https://doi.org/10.1016/j.bpobgyn.2017.09.003
[11]
Mara, M., Maskova, J., Fucikova, Z., Kuzel, D., Belsan, T. and Sosna, O. (2008) Midterm Clinical and First Reproductive Results of a Randomized Controlled Trial Comparing Uterine Fibroid Embolization and Myomectomy. CardioVascular and Interventional Radiology, 31, 73-8557. https://doi.org/10.1007/s00270-007-9195-2
[12]
Torre, A., Fauconnier, A., Kahn, V., Limot, O., Bussierres, L. and Pelage, J.P. (2017) Fertility after Uterine Artery Embolization for Symptomatic Multiple Fibroids with No Other Fertility Factors. European Radiology, 27, 2850-2859.
https://doi.org/10.1007/s00330-016-4681-z
