Medical Case Reports

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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].

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

1. Chan YC, Bird LM (2004) Vertically transmitted hypoplasia of the abdominal wall musculature. Clinical Dysmorphology 13: 7-10.
2. Digilio MC, Capolino R, Dallapiccola B (2008) Autosomal dominant transmission of nonsyndromic diastasis recti and weakness of the linea alba. AJMG 146A: 254-256.
3. Samal SK, Rathod S (2015) Prune Belly syndrome: A rare case report. J Nat Sci Biol Med 6: 255-257.