Laparoscopic-Guided Vaginal Excision of Posterior-Lateral Vaginal Fibroid

Introduction

Leiomyomas are benign mesenchymal tumors commonly known to occur in the uterus. Extrauterine sites of leiomyomas include round, broad, and uterosacral ligaments; ovary; inguinal canal; and the vagina. Vaginal wall leiomyoma is a rare benign tumor. It can be misleading and pose diagnostic difficulties. Several cases of anterior vaginal wall fibroids have been reported. ¹ The fibroid mass may occur anywhere along the vaginal tube and is usually localized, mobile, nontender, and well circumscribed. ¹ Clinical presentation is variable. Depending upon their size, they can be asymptomatic or present with urinary symptoms, pelvic pain, or dyspareunia.

Usually these tumors are single, benign, and slow growing, but sarcomatous change has been reported. ²

Diagnosis with ultrasonography alone may be difficult, but magnetic resonance imaging is helpful. ³ Nevertheless, histopathologic diagnosis is confirmatory.

A case of posterolateral vaginal wall fibroid, which was removed vaginally under laparoscopic guidance because of the close proximity to the ureter, is presented.

Case

A 35-year-old woman presented with a history of pelvic and vaginal pain of 3 months' duration. The pain was a dull ache. She also reported feeling a mass in the vagina. She had no menstrual problems. She was generally fit and well, with no other significant medical history.

Pelvic examination revealed a normal sized uterus. In the right posterior fornix of the vagina, a 3×3 cm hard lesion was felt, which was mildly tender.

Ultrasound examination revealed normal appearance of the uterus and ovaries in addition to a 3.6 cm solid mass in the right posterolateral fornix, separate from the broad ligament and right ovary, the nature of which was uncertain. Appearances were not typical of a cyst or a lymph node. As the patient was still in pain, an excision biopsy was planned.

Because of the ambiguous nature of the mass and the structures the mass was close to, a laparoscopy was performed, which revealed the mass to be bulging through the posterolateral pelvic side wall on the right side, just under the right uterosacral ligament, and a few mm away from the right ureter (Fig. 1). The right ureter was localized by laparoscopy, as it was visualized passing under the visceral peritoneum on the right lateral pelvic side wall, and upon touching the ureter with a laparoscopic probe, peristalsis was noticed. The mass was then excised by a vaginal approach under laparoscopic guidance. A vertical incision was made on the vaginal wall directly over the mass, and no energy source was used for fear of any thermal damage it might cause to the ureter. Once the plane of dissection was obtained and the fibroid capsule was identified, the mass was then enucleated by sharp and blunt dissection of the fibroid capsule from the rest of the vaginal skin and tissue. The fibroid was then completely removed without risking the ureter, which was continuously identified and visualized by laparoscopy during the procedure. The leimoyoma`s dead space was then obliterated by applying multiple interrupted Vicryl 2/0 sutures, making sure that no sutures involved the ureter, and hemostasis was then secured. The vaginal wall was closed with absorbable Vicryl 2/0 sutures. Blood loss was minimal. The ureter was checked to be intact, with active peristalsis observed above and below the site of the removed fibroid, with no intraperitoneal or retroperitoneal bleeding seen during the entire procedure, and there being clear urine output during and after the procedure. Therefore, most of the procedure was performed vaginally under laparoscopic guidance in order to continuously observe the ureter during enucleation and excision of the fibroid and during closure of the dead space.

OPEN IN VIEWER

FIG. 1.

Fibroid bulging close to the right ureter at laparoscopy.

Results

The patient made an uneventful recovery and was discharged home the next day. She reported no problems at follow-up.

Macroscopic appearance of the mass suggested a fibroid with typical whorled appearance (Fig. 2). Histology confirmed this to be a benign vaginal wall leiomyoma.

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FIG. 2.

Fibroid mass post-removal.

Discussion

Leiomyomas are benign, mesenchymal, monoclonal tumors that typically originate from myometrium smooth muscle cells, although atypical sites such as the vagina, vaginal vault post- hysterectomy, lungs, vascular structures, and retroperitoneal area have been reported. ⁴

Leiomyoma of the vagina is a rare condition. The earliest reference made to such a tumor is attributed to Denys De Leyden in 1773, and the first review of the literature concerning such tumors was published in 1882. It is estimated that ∼300 leiomyomas of the vagina have been reported in the world literature. ⁵

It presents and is reported most commonly on the anterior vaginal wall. ¹ Most vaginal fibroids can be removed via a vaginal approach. Posterolateral vaginal fibroids are best removed surgically via a vaginal approach under laparoscopic guidance. During such a procedure it is important to be vigilant with regard to the ureter. In case of tumors >8 cm, however, an abdominoperineal approach is preferred. ⁶

Conclusions

Close proximity of posterolateral vaginal wall fibroids to the ureter makes the removal of such tumors under laparoscopic guidance much safer, and is highly recommended.