S. Wali, T. Amin, T. Miskry, T. SetchellSt Mary’s Hospital, Paddington, London

BACKGROUND

Submucosal (SM) fibroids represent 5–10% of uterine leiomyomata, migrating from the myometrium towards the endometrial cavity, causing abnormal uterine bleeding and subfertility. The Wamsteker classification defines uterine fibroid location. Hysteroscopic Myomectomy (HM) is a daycase, minimally invasive surgical procedure for resecting Type G0 and G1 fibroids.

The Case

A 31 year-old nulliparous woman presented with dysmenorrhea, menorrhagia and pressure symptoms. Ultrasound and MRI demonstrated a 56mm diameter fibroid, occupying the endometrial cavity from the fundus to the internal cervical os. She had already undergone outpatient hysteroscopic assessment, also confirming a significant submucosal fibroid. Imaging was reviewed in the departmental Fibroid MDT, recommending either HM or uterine artery embolization, and she opted for HM.

After two months of GnRH analogue for fibroid shrinkage, Hysteroscopy was performed under general anaesthesia with a 10mm rigid bipolar resectoscope. A large Type G2 SM fibroid (approximately 40-50% cavity indentation) was seen occupying the majority of the endometrial cavity. During distension with 200 mmHg normal saline (Biegler Pressure Infusor), the fibroid was seen to retract entirely from the cavity, leaving a ‘normal’ cavity with a circular ridge of myometrium around the retracted fundal fibroid, making it apparent that resection of this intramural (IM) fibroid through the hysteroscopic approach was inappropriate. A laparoscopic myomectomy was discussed and scheduled for a later date.

IMAGING

DISCUSSION

Despite low pressure outpatient hysteroscopy and imaging with MDT review suggesting a significant intra-cavity fibroid, it was entirely reducible to an intramural location, visualised in real time, with pressurised hysteroscopic distention fluid. This phenomenon, seen with increasing distension pressure, has been described as the ‘sinking myoma’.

CONCLUSIONS

Imaging, whilst vital for pre-operative fibroid mapping, is less useful than hysteroscopy in assessing the degree of intra-cavity involvement. Fibroid mapping allows for procedure planning and appropriate discussion of operative risks and expectations with patients.

Video Link: https://vimeo.com/320629585

The “Sinking” Fibroid

HYSTEROSCOPY  

LAPAROSCOPY  

Low pressure  

High pressureIM fibroid

 

IM fibroid 

? SM fibroid 

US – Submucosal fibroid

MRI – Submucosal fibroid