A it and giving the classical view

A RARE CASE OF PSEUDOCERVICAL FIBROID
ABSTRACT- Cervical fibroids are rare tumors accounting for 2% of all fibroids. We present a case report of Pseudocervical fibroid where myomectomy was performed by approaching it by opening the broad ligament. On laparotomy it was as deeply filling the pelvis, with uterus on top of it and giving the classical view reported in literature as “the Lantern on the top of St.Pauls Catheterdal.” Despite its location in the deep pelvis and the presence of adhesions due to previous surgery, a successful myomectomy was performed with mild hemorrhage without any complications
INTRODUCTION-Cervical fibroids account for 2% of all fibroids and they can originate from either supra-vaginal or vaginal portion of cervix.1 They are classified into True cervical fibroids which may be anterior, posterior, lateral & central depending on their site of origin. The other type is the False cervical fibroid (Pseudocervical) which may be intra-ligamentary, retroperitoneal and non-capsulated. Large cervical fibroids are challenging to manage and can pose surgical difficulties at the time of either hysterectomy or myomectomy and have increased risk of intraoperative bleeding and urinary tract injuries. Surgical management presents a technical challenge due to distorted anatomy making identification of uterine vessels and ureter difficult and obscuration of visual field due to large size of the fibroids which leads to poor uterine mobility.
CASE REPORT-35 years old, married since 15 years, P1L1 was admitted with complaints of pain in the lower abdomen since 2 months. She had no menstrual complaints. She was diagnosed as Hypertension 1 year back and was on Tablet Amlodipine 5 mg OD. She had one male child 12 years back and was delivered by lower segment cesarean section. She had no other surgery done in the past. On general examination her vital parameters were in normal limits. On per abdomen examination there was a infraumbilical vertical midline scar of previous lower segment cesarean section present, abdomen was soft with no guarding tenderness rigidity. On per speculum examination cervix was high up and healthy. On Bimanual examination uterus was 14 to 16 weeks and a firm mass of 10 ×8 cm was felt in the posterior wall and cervix. Her pre-operative blood investigations were normal and Pap smear was severe inflammatory. On ultrasonography of the Pelvis the uterus was elongated, bulky, 13 cm in size and a large ovoid heterogeneously mildly hypoechoic 8×7×5.9 cm fibroid was seen centrally and predominately posteriorly in the lower body and cervix with mild increase in intra and peripheral vascularity. Both ovaries were normal. In view of above findings and patients desire of retaining her fertility she was posted for Myomectomy sos Hysterectomy after anesthesia fitness and reserving blood. She was given spinal anesthesia for surgery.
Abdomen was opened by a infraumbilical midline incision. Dense adhesions were encountered between the anterior abdominal wall and omentum which were separated by sharp dissection. The parieties were adherent completely to the anterior wall of the uterus and only the right cornual structures were seen. A posterior cervical fibroid of 10×8 cm was felt posteriorly and was growing in the posterior leaflet of right broad ligament and the uterus was normal in size. The adhesions between the anterior wall of the uterus and the parieties were separated by sharp and blunt dissection and the cervical fibroid was pushed up. Right side ureter was traced to see its course and relation with the fibroid. Right sided round ligament was divided in order to open the anterior leaflet of right broad ligament. This route was chosen to reach the fibroid which was a pseudo cervical fibroid arising from the posterior wall and growing in the right broad ligament. This fibroid was pushed from below in the operative field and dissected and enucleated intracapsularly and sent for histopathology. A clamp was applied at the base of the fibroid in view of vascularity at the base and pedicle was transfixed with polyglactin no.1. Dead space in this cavity was obliterated by taking multiple interrupted sutures in the cavity with polyglactin no 1 and redundant part of the pseudo-capsule was excised and remaining edges sutured with continuous sutures using polyglactin no 1. Incision on anterior leaflet of the broad ligaments were repaired with Polyglactin no 1-0 by taking simple interrupted sutures and right ligament was reconstructed. Left sided ovary was normal and left tube was not visualized. Hemostasis was confirmed al a blood pressure of 120/80 mm of mercury Oxidized regenerated cellulose (surgical Absorbable Haemostat) were kept over the suture line to prevent adhesions. Patient withstood the procedure well and patient was discharged on Day 5.
DISCUSSION
The presentation of cervical fibroid usually depend on the location and can present with symptoms like menstrual irregularities, constipation, frequency of urination, urinary retention, dyspareunia and post coital bleeding.3 The large size of cervical fibroid causes anatomical distortion of ureter, bladder and uterine vessels and thus increasing risk of injury to these structures. The progression in the number, size and growth of cervical fibroids are unpredictable and they usually do not become become cancerous. They are less likely to shrink on their own until after menopause.
In our case it was a posterior cervical fibroid which was arising from the supra-vaginal part of the cervix and was growing in the posterior leaf of right broad ligament. Due to this unusual location the ureter was expected to lie not only lateral to the fibroid but also on the top of it. This fibroid was reached by opening the anterior leaflet of right broad ligament by dividing the right round ligament. The key principle of removing such fibroids is to stay always intra-capsular while doing dissection and enucleation to prevent ureteric injury. When approaching through this route the relation to the ureter is extremely important which will extracapsular.3 The knowledge of the above facts helped us to perform Myomectomy without damaging the ureter. We followed the technique of displacing the fibroid upwards & removal of fibroid intra-capsularly, despite presence of large dilated vessels which were seen over the capsule and medially.
Preoperative stenting of the ureters and intra-operative delineation of ureters are essential precautions which should be followed to avoid injury to the ureters. In spite of the difficult location of fibroid, large size, vascularity, its close proximity to the ureters and adhesions a successful myomectomy was possible without significant hemorrhage. A good knowledge of the anatomical structures is important for performing myomectomy for cervical fibroid. Preservation of fertility factor should always be kept in the mind before proceeding with surgery for such difficult cases but informed and written consent for probable hysterectomy should always be taken in anticipation of major blood loss and operative challenges when faced with a cervical fibroid.

REFERENCES-
1. Bhatla N. Tumors of the corpus uteri. In: Jeffcoates Principles of Gynaecology. 5th ed. London: Arnold Publisher; 2001. pp. 470.
2. Buttram VC Jr., Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981;36:433
3. Singh S, Chaudhary P. Central cervical fibroid mimicking as chronic uterine inversion, Int J Reprod contracept Obstet Gynnaecol. 2013;2(4):687-88

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