Abstract
Background:
A deeply placed, cul de sac retroperitoneal myoma in a young nullipara woman is rare and is a surgical nightmare owing to the technical challenge associated with performing a myomectomy in a small limited space without damaging the adjoining structures in the area.
Case:
A 34-year-old nullipara with no sexual exposure developed a large retroperitoneal myoma. She underwent a laparotomic myomectomy. This abdominal myomectomy was performed to remove a 490-g, 13 × 10 × 12–cm, retroperitoneal deep-seated cul de sac leiomyoma. The operation involved using finger-swiping movements and a myoma screw to excise the deeply placed myoma without damaging the patient's uterus and adjoining adnexa.
Results:
This patient's postoperative period was uneventful. After 48 hours, the drain and Foley's catheter, that had been placed during the operation, were removed, and she was discharged. Histopathology confirmed that the tumor was a benign leiomyoma.
Conclusions:
Good preoperative clinical and imaging assessment, along with certain modifications of the standard abdominal myomectomy procedure, can be beneficial when surgically addressing a large, retroperitoneal, deeply placed cul de sac myoma.
Introduction
Leiomyomas of the uteri, arising from the smooth-muscle cells of the myometrium, are the most-common benign tumors of the female genital tract. 1 They are found predominantly in women of reproductive age and usually decrease after menopause, as hormonal stimulation by estrogen, progesterone, and other growth factors play a pivotal role. 2 Clinically significant, large retroperitoneal myomas obscuring the cul de sac are rare. 3 They commonly present with lower-abdominal pain and pelvic-pressure symptoms such as frequent urination, dyspareunia, and constipation. 4
Laparotomic myomectomy for removing large retroperitoneal fibroids, especially in women desirous of fertility preservation, is a surgical challenge due to constraints of working in a narrow operative field. There are a risks of bowel, bladder, and ureteric injuries as well as significant blood loss and potential unplanned hysterectomy. The repair of the big cavity postmyomectomy make this procedure a technical challenge even further. 5 Literature on abdominal myomectomy for large retroperitoneal cul de sac myomas was limited up till the past decade. For any woman desirous of fertility in the future, myomectomy can improve her chances of pregnancy by restoration of her normal anatomy. This article describes the current authors' technique for performing a myomectomy with uterine preservation for a nulligravida woman with a large, deep-seated retroperitoneal myoma obliterating the cul de sac.
Case
A 34-year-old nullipara with no sexual exposure presented with complaints of abdominal fullness and difficulty in micturition of 6 months' duration. She also complained of having constipation and, occasionally, a foul-smelling, greenish vaginal discharge. She had previously been reviewed at a private clinic for the same complaints. At that clinic, ultrasonography (USG) showed a 10-cm leiomyoma; thus, a laparotomy was attempted. However, due to intraoperatively noting the presence of a large retroperitoneal mass indicating that she had a cervical myoma, surgery was abandoned after a computed tomography (CT)–guided biopsy of the mass showed that this was a spindle-cell mesenchymal neoplasm.
She then presented to the current authors for definitive treatment. She had no menstrual complaints. Her medical and family history was not significant for any chronic diseases or malignancies. A general examination did not detect any abnormality except a healing midline laparotomy scar. Her body mass index was 22.2. An abdominal examination showed a firm, nontender abdominopelvic mass, approximately the size of a 14-week pregnancy, with restricted mobility. There was no evidence of ascites. A vaginal examination revealed a mass felt posteriorly through all of the fornices. The abdominopelvic mass was also felt during the bimanual examination. The uterus could not be felt separately from the mass. The cervix was not visualized on speculum examination.
This patient's hematologic and biochemistry profiles were normal with a hemoglobin level of 12.4g/dL. Abdominal USG showed a 13 × 11 × 12–cm pelvic mass arising from the posterior surface of the lower-uterine segment (Fig. 1A). A CT scan showed a 13.6 × 12–cm, cul de sac retroperitoneal mass indicating a myoma (Fig. 1B). No evidence of hydronephrosis was noted.
This patient was underwent another laparotomy and a myomectomy, with adequate counseling about the possibility of a hysterectomy. After catheterization of her bladder, a vertical, subumbilical midline incision was made. This exploratory laparotomy revealed a huge, retroperitoneal cul de sac myoma, measuring ∼13 × 10 × 12 cm, filling the pelvis, with normal corpus uteri pushed anteroinferiorly. Both fallopian tubes and ovaries were normal on gross appearance.
Engorged neovascularization was noted on the myoma's surface. Bilateral temporary uterine artery ligation was performed using a Number 14 Foley's catheter. The peritoneum over the tumor was incised at its upper border and pushed down. The capsule of the myoma was incised at its upper portion for ∼4–5 cm, using electrocautery. Then, the index finger of the surgeon's left hand was inserted through the incision to ascertain the plane of cleavage between the myoma and its capsule. The incision was then enlarged across the capsule and the myoma was enucleated gradually down to its base by using the fingers of the surgeon's right hand through the proper plane of cleavage in a sweeping movement to “shell it out.” Once an adequate plane was created with the fingers, a Doyen's myoma screw (Fig. 2A) was used to fix the deep-seated myoma and enucleate it en mass from the posterior uterine surface. The base of the capsule was electrocoagulated before complete enucleation of the myoma.
The tumor-bed depth was assessed and the cavity was obliterated with continuous concentric layers of spiral stitches with polyglact 0, in a “bottom-up” fashion. A cul de sac drain was placed. The temporary uterine artery ligatures were released, and uterine perfusion was checked.
The patient's estimated blood loss was ∼100 mL. The operative time was 90 minutes. The excised myoma (Fig. 2B) was 13 × 10 × 12 cm and weighed 490 g.
Results
This patient's postoperative period was uneventful. After 48 hours, the drain and the Foley's catheter were removed, and she was discharged. Histopathology confirmed that the tumor was a benign leiomyoma.
Discussion
A large retroperitoneal myoma deeply located in the cul de sac is rare. Kho and Nezhat suggested iatrogenic parasitic myoma formation as the cause of a retroperitoneal myoma. 6 The pathologic origin of retroperitoneal lesions remains unclear. They represent synchronous or metastatic primary lesions, either arising from the hormonally sensitive smooth-muscle component or from the embryonal remnants of the Müllerian or Wolffian duct. 7 In addition, Kang et al. proposed primary multifocal origins of retroperitoneal fibroids. 8
The first reported case in the literature dates back to 1903, by Lewers, who described an abdominal myomectomy to remove a 13-lb., retroperitoneal cervical myoma. 9
When fertility preservation is the endpoint of management, it becomes essential to be aware of retroperitoneal pelvic anatomy to ensure a successful outcome of this surgery. These patients can present with pressure symptoms with or without menstrual complaints. Even with the modern armamentarium of imaging modalities such as USG, CT, and magnetic resonance imaging, a definitive preoperative diagnosis remains a challenge. In most of the available literature on retroperitoneal leiomyomas, preoperative diagnoses of either subserous fibroid, ovarian malignancies or fibromas were made. 10
Abdominal myomectomy should be considered the “gold standard” of choice for a fertility-preserving procedure when operating on such large fibroids. The key technique in myomectomy should be adhering to the basics of Bonney's principles to create an adequate plane of cleavage between the tumor and its capsule. Use of the surgeon's fingers for “sweeping out” the myoma and Doyen's myoma screw for fixing the deeply located tumor played a key role in this technically difficult case. Obliteration of dead raw space left behind after the myomectomy with concentric spiral sutures helped prevent hemorrhage and hematoma formation. Laparotomy in such cases allows enough working space for traction and countertraction, thus achieving rapid enucleation of such a large myoma. 11
Conclusions
A laparotomic myomectomy for a huge cervical myoma should be offered as the standard treatment of choice for patients desiring fertility preservation. The surgeon can diligently innovate few technical modifications of the classic abdominal myomectomy while adhering to the basic principles. This will not only prevent intraoperative complications but will also ensure an optimal surgical outcome.
Footnotes
Acknowledgments
The authors would like to thank Asia Pacific Association of Gynecological Endoscopy and the Department of Obstetrics and Gynecology, at Chang Gung Memorial Hospital at Linkou, Taiwan, for their academic support.
Author Disclosure Statement
No financial conflicts of interest exist.
Funding Information
No funding was received for this study.