A Rare Isolated Vaginal Myoma

Introduction

The most common benign tumors of the female genital tract are uterine fibroids or leiomyomata, which affect 20%–30% of reproductive-age women. ¹ There are many types of leiomyomata classified by an International Federation of Gynecology and Obstetrics (FIGO) system, which is known as a leiomyomata subclassification system. ² Type 0 is a pedunculated, intracavitary submucous myoma; type 1 is a >50% intramural submucosal myoma; type 2 is a ≥50% intramural submucosal myoma; type 3 is a 100% intramural myoma that contacts the endometrium; type 4 is an intramural myoma; type 5 is a subserosal ≥50% intramural myoma; type 6 is a subserosal <50% intramural myoma; type 7 is a pedunculated subserosal myoma; and type 8 comprises others, such as cervical or parasitic myomas. ² However, the current case study involved a rare isolated myoma that is not included in the FIGO leiomyoma subclassification system.

Magos et al., who were the first to report about vaginal myomectomy in 1994, showed a vaginal route for approaching a uterine myoma surgically by making a vaginal incision through which the myoma was excised and uterine suturing was performed.^3,4 Vaginal myomectomy is an alternative procedure for the treatment of vaginal myomas. This current report is about a vaginal myomectomy approach to an anterior, vaginal isolated myoma, of ∼5.9 cm, without making any abdominal skin incisions.

Case

A 41-year-old female (gravida 2, para 2, with both normal deliveries), with a regular menstrual cycle, came to an outpatient clinic due to having an increasing amount of watery, yellowish, odorless vaginal discharge for ∼1 month. Transvaginal ultrasonography, as shown in Figure 1, revealed an anterior, isolated, rare vaginal myoma, measuring 5.9 × 5.3 cm; it compressed the urinary bladder, urethra, and cervix, and had an endometrial thickness of 1.58 cm. As shown in Figure 2, magnetic resonance imaging (MRI) revealed a well-defined, homogenous, isolated vaginal mass, measuring 5.9 × 5.3 × 5.0 cm, arising from the anterior superior segment of the vagina. The MRI imaging features suggested that the mass was most likely to be a leiomyosarcoma of the vagina, with a differential diagnosis of a leiomyoma with myxoid degeneration and no evidence of nodal or distant lesions.

OPEN IN VIEWER

FIG. 1.

Transvaginal ultrasonography showed an anterior, isolated, rare vaginal myoma that was 5.9 × 5.3 cm; it compressed the urinary bladder, urethra, and cervix.

OPEN IN VIEWER

FIG. 2.

Magnetic resonance imaging showed a large, isolated, rare, anterior vaginal myoma that was 5.9 × 5.3 × 5.0 cm; it compressed the urinary bladder, urethra, and cervix.

In the operative theater, upon inspection of the vagina, a nodular myoma of ∼6 cm was found anteriorly in the vaginal wall and very close to the bladder base. The mass was separated from the urethra. Normal sodium saline solution (3 cubic cm) was injected into the mass. A 2-cm transverse vaginal incision was made below the vaginal rugae and was deepened down to the plane of the vaginal myoma. The edges of the mass were excised by using bipolar scissors and electrocauterization. The homogeneous vaginal mass weighed 52 g. The edges of the vagina were sutured with Vicryl 2-0. The vaginal myomectomy operation was performed completely. The mass was sent for pathologic diagnosis.

Results

Pathologic testing revealed that the mass was a leiomyoma of the vagina.

Discussion

In 1994, there was a report about a vaginal procedure as an alternative approach to abdominal or laparoscopic surgery for myomectomy; this report stated that this approach produced superior cosmetic results. ³ Conventional, rather than miniature, instruments can be used for a vaginal procedure. Moreover, these instruments are more efficient for handling tissues with gross pathology. Stronger grasping forceps can be used, and suturing the uterus is tremendously easier, which should make the suture repair stronger and less likely to dehisce during pregnancy in the future. Furthermore, surgeons who perform vaginal myomectomies surely have all the tactile advantages of conventional surgery, which are absent from endoscopic procedures. ⁵ There have been some reports of uterine ruptures in future pregnancies after patients underwent laparoscopic myomectomy; these ruptures were due to the uterine repairs being performed with low-strength laparoscopic suturing.^6,7

In the current case, the MRI of the vaginal myoma—with the differential diagnosis per that MRI of the leiomyosarcoma of the vagina—showed that the mass totally filled the vaginal cavity. Thus, other surgeons might have thought that it was not safe to do a vaginal procedure. Other surgeons might have used an abdominal procedure to perform a hysterectomy with removal of the vaginal myoma via an abdominal route.

The current case report was about an isolated, anterior vaginal myoma, measuring ∼5.9 cm, that was excised with a vaginal myomectomy. This study shows that isolated anterior vaginal myomectomy can be a safe vaginal route for selected patients, with no morbidity, great success rates, and no uterine ruptures in subsequent pregnancies.

Conclusions

A rare, large, isolated vaginal myoma—which is not included in the FIGO classification system—can be managed by vaginal myomectomy. This is a safe procedure that can be performed with no abdominal skin incisions, minimal blood loss during the procedure, and fast recovery after the operation.