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Lantern on Dome of St. Paul’s – A Huge Cervical Fibroid

Monika Thakur1, Sandeep Rathore1, Aditi Jindal1, Angesh Thakur2, Kunal Mahajan3* and Gunjan Gupta4

1Department of Obstetrics and Gynaecology, Indira Gandhi Medical College, Shimla, India

2Department of Surgery, Indira Gandhi Medical College, Shimla, India

3Department of Cardiology, Holy Heart Advanced Cardiac Care and Research Center, Rohtak, India

4Department of ENT, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Haryana, India

*Corresponding Author:
Kunal Mahajan
Consultant Cardiologist, Department of Cardiology
Holy Heart Advanced Cardiac Care and Research
Center, Rohtak, Haryana- 124001, India
Tel: +91-8628864820
E-mail: [email protected]

Received date: February 12, 2018; Accepted date: February 24, 2018; Published date:February 26, 2018

Citation: Thakur M, Rathore S, Jindal A, Thakur A, Mahajan K, et al. (2018) Lantern on Dome of St. Paul’s – A Huge Cervical Fibroid. Med Case Rep Vol. 4 No. 2:i60. doi:10.21767/2471-8041.100095

 
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Abstract

A 30-year-old woman, with an obstetrics history of gravid 3 para 2, last child birth by classical caesarean section, complained of history of retention of urine twice in past 3 months along with menorrhagia. The patient was told to have lower segment leiomyoma located on the lower segment when caesarean section was performed 3 years back. She subsequently was lost to follow up till she become symptomatic for her disease. Bimanual examination revealed a solid mass extending till umbilicus. Abdominopelvic examination revealed a huge myoma filling and enlarging the cervix. Ultrasonography showed a 28 × 15 cm myoma in the cervical region and bilateral hydrourteronephrosis.

Clinical Image

A 30-year-old woman, with an obstetrics history of gravid 3 para 2, last child birth by classical caesarean section, complained of history of retention of urine twice in past 3 months along with menorrhagia. The patient was told to have lower segment leiomyoma located on the lower segment when caesarean section was performed 3 years back. She subsequently was lost to follow up till she become symptomatic for her disease. Bimanual examination revealed a solid mass extending till umbilicus. Abdominopelvic examination revealed a huge myoma filling and enlarging the cervix. Ultrasonography showed a 28 × 15 cm myoma in the cervical region and bilateral hydrourteronephrosis. On intravenous urography both mid ureters were found outward displaced with grade 1 HDN. We performed exploratory laparotomy through previous scar, preoperatively a central cervical myoma of size 30 × 18 cm filling whole of the pelvis was identified, elevated on top of which was lying the uterus like “the lantern on top of St. Paul’s” (Figure 1). The myoma was first enucleated followed by hysterectomy using standard techniques. Patient was discharged on fifth postoperative day without any complications. The histopathological examination confirmed the diagnosis of leiomyoma. Cervical myomas account for less than 5% of uterine myomas. [1] They may be categorized as those that occur at a subserosal location (i.e., extracervical type) and those that occur within the cervix (i.e., intracervical type) [2]. Central cervical fibroid, either of interstitial or of submucous origin, expands the cervix equally in all directions. Cervical fibroid poses enormous surgical difficulty by virtue of their relative inaccessibility and proximity to the anterior bladder, posterior rectum and distorting the normal anatomical relationship of pelvic structures. In case of hysterectomy the principal to be followed is enucleation followed by hysterectomy in order to minimise injury to ureter and also ureteric stenting can be done prior to surgery. Intracapsular enucleation of fibroid is the best approach to prevent injury to bladder and ureter [3].

medical-case-reports-cervical

Figure 1: Normal uterus and ovaries sitting on top of the central cervical fibroid “the lantern on top of the St. Paul’s”.

Learning Points

1. Cervical fibroid account for less than 5% of uterine myomas. Huge cervical fibroid is even rarer.

2. In case of hysterectomy, the principal to be followed is enucleation followed by hysterectomy to minimize injury to ureter and also uretric stenting can be done prior to surgery.

3. Intra-capsular enucleation of fibroid is the best approach to prevent injury to bladder and ureters. For enucleation, the capsular incision may be transverse or vertical.

References

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