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Parasitic myomas after laparoscopic myomectomy: case report
CASE REPORT Parasitic myomas after laparoscopic myomectomy: case report Jason H. Epstein, M.D., Edward J. Nejat, M.D., M.B.A., and Tony Tsai, M.D. Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
Objective: To report a case of a woman who presented with parasitic myomas 27 months after laparoscopic myomectomy. Design: Case report. Setting: University medical center. Patient(s): A 31-year-old G0 woman who had a previous history significant for laparoscopic myomectomy with morcellation 27 months before. Intervention(s): Repeat laparoscopic myomectomy and review of video footage from previous myomectomy. Main Outcome Measure(s): Pathology report. Result(s): Repeat laparoscopic examination revealed two pedunculated and two parasitic myomas. Review of video footage from initial surgery revealed pieces of myoma dispersed within pelvis during morcellation. Conclusion(s): Pieces of initial myoma dispersed within the pelvis during morcellation may have developed into parasitic myomas. (Fertil Steril 2009;91:932.e13–e14. 2009 by American Society for Reproductive Medicine.) Key Words: Parasitic myomas, parasitic fibroids, morcellation, laparoscopic myomectomy
The first laparoscopic myomectomy was reported by Semm in 1979 (1). The technique of morcellation was introduced to laparoscopic myomectomy in the mid 1990s, allowing for improved results, less blood loss, and fewer complications in large myomas (2). Few complications have been reported, and laparoscopic myomectomy is generally considered to have better a morbidity profile than myomectomy via laparotomy (3). Although recurrence rates for uterine myomas range from 22% to 62% (4, 5), recurrence of parasitic myomas is rare. A 29-year-old G0 woman with no significant past medical or surgical history presented with menorrhagia and was found to have an anterior myoma measuring 5 5 5 cm. The patient underwent laparoscopic myomectomy with removal via Gynecare X-Tract Tissue Morcellator.
increased vascularity and was noted on ultrasound to be completely separate from the uterus. The patient was taken back to the operating room, where a survey of the abdomen revealed two pedunculated myomas and two parasitic myomas. The pedunculated myomas were
FIGURE 1 Eight-centimeter parasitic myoma with blood supply solely derived from sigmoid colon.
Eighteen months after surgery, the patient presented again with pelvic pain and pressure and was found on ultrasound to have a pedunculated myoma measuring approximately 3.8 2.4 4.3 cm. Nine months later, her symptoms worsened and the mass had increased in size to 7.8 5.5 5.2 cm with Received April 29, 2008; revised August 4, 2008; accepted August 7, 2008. J.E. has nothing to disclose. E.N. has nothing to disclose. T.T. has nothing to disclose. Presented at the 2007 Annual Meeting of the Society for Reproductive Endocrinology, Washington, D.C. Reprint requests: Tony Tsai, M.D., Department of OB/GYN, New York Hospital – Queens, 56-45 Main Street, Flushing, New York, 11355 (FAX: 718-261-9068; E-mail: [email protected]).
932.e13
Epstein. Myomas after laparoscopic myomectomy. Fertil Steril 2009.
Fertility and Sterility Vol. 91, No. 3, March 2009 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/09/$36.00 doi:10.1016/j.fertnstert.2008.08.014
found on the anterior wall and in the fundus. One parasitic myoma was found in the omentum, measuring 3 cm in size, and an 8 cm myoma was found that derived its blood supply solely from the sigmoid colon (Fig 1). The large myoma was removed via morcellation. Upon review of video taken during the initial operation, it was noted that during morcellation, pieces of the myoma were dispersed throughout the pelvis. It is our thought that some of these pieces of myoma may have contributed to the development of the recurrent myomas, and particularly the parasitic myomas. We suggest that care is taken to remove all pieces of myomas after morcellation.
Fertility and Sterility
REFERENCES 1. Semm K. New methods of pelviscopy (gynecologic laparoscopy) for myomectomy, ovariectomy, tubectomy and adnectomy. Endoscopy 1979;11: 85–93. 2. Rossetti A, Sizzi O, Chiarotti F, Florio G. Developments in techniques for laparoscopic myomectomy. JSLS 2007;11:34–40. 3. Sizzi O, Rossetti A, Malzoni M, Minelli L, La Grotta F, Soranna L, et al. Italian multicenter study on complications of laparoscopic myomectomy. J Minim Invasive Gynecol 2007;14:453–62. 4. Doridot V, Dubuisson JB, Chapron C, Fauconnier A, Babaki-Fard K. Recurrence of leiomyomata after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2001;8:495–500. 5. Hanafi M. Predictors of leiomyoma recurrence after myomectomy. Obstet Gynecol 2005;105:877–81.
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Objective: To report a case of a woman who presented with parasitic myomas 27 months after laparoscopic myomectomy. Design: Case report. Setting: University medical center. Patient(s): A 31-year-old G0 woman who had a previous history significant for laparoscopic myomectomy with morcellation 27 months before. Intervention(s): Repeat laparoscopic myomectomy and review of video footage from previous myomectomy. Main Outcome Measure(s): Pathology report. Result(s): Repeat laparoscopic examination revealed two pedunculated and two parasitic myomas. Review of video footage from initial surgery revealed pieces of myoma dispersed within pelvis during morcellation. Conclusion(s): Pieces of initial myoma dispersed within the pelvis during morcellation may have developed into parasitic myomas. (Fertil Steril 2009;91:932.e13–e14. 2009 by American Society for Reproductive Medicine.) Key Words: Parasitic myomas, parasitic fibroids, morcellation, laparoscopic myomectomy
The first laparoscopic myomectomy was reported by Semm in 1979 (1). The technique of morcellation was introduced to laparoscopic myomectomy in the mid 1990s, allowing for improved results, less blood loss, and fewer complications in large myomas (2). Few complications have been reported, and laparoscopic myomectomy is generally considered to have better a morbidity profile than myomectomy via laparotomy (3). Although recurrence rates for uterine myomas range from 22% to 62% (4, 5), recurrence of parasitic myomas is rare. A 29-year-old G0 woman with no significant past medical or surgical history presented with menorrhagia and was found to have an anterior myoma measuring 5 5 5 cm. The patient underwent laparoscopic myomectomy with removal via Gynecare X-Tract Tissue Morcellator.
increased vascularity and was noted on ultrasound to be completely separate from the uterus. The patient was taken back to the operating room, where a survey of the abdomen revealed two pedunculated myomas and two parasitic myomas. The pedunculated myomas were
FIGURE 1 Eight-centimeter parasitic myoma with blood supply solely derived from sigmoid colon.
Eighteen months after surgery, the patient presented again with pelvic pain and pressure and was found on ultrasound to have a pedunculated myoma measuring approximately 3.8 2.4 4.3 cm. Nine months later, her symptoms worsened and the mass had increased in size to 7.8 5.5 5.2 cm with Received April 29, 2008; revised August 4, 2008; accepted August 7, 2008. J.E. has nothing to disclose. E.N. has nothing to disclose. T.T. has nothing to disclose. Presented at the 2007 Annual Meeting of the Society for Reproductive Endocrinology, Washington, D.C. Reprint requests: Tony Tsai, M.D., Department of OB/GYN, New York Hospital – Queens, 56-45 Main Street, Flushing, New York, 11355 (FAX: 718-261-9068; E-mail: [email protected]).
932.e13
Epstein. Myomas after laparoscopic myomectomy. Fertil Steril 2009.
Fertility and Sterility Vol. 91, No. 3, March 2009 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/09/$36.00 doi:10.1016/j.fertnstert.2008.08.014
found on the anterior wall and in the fundus. One parasitic myoma was found in the omentum, measuring 3 cm in size, and an 8 cm myoma was found that derived its blood supply solely from the sigmoid colon (Fig 1). The large myoma was removed via morcellation. Upon review of video taken during the initial operation, it was noted that during morcellation, pieces of the myoma were dispersed throughout the pelvis. It is our thought that some of these pieces of myoma may have contributed to the development of the recurrent myomas, and particularly the parasitic myomas. We suggest that care is taken to remove all pieces of myomas after morcellation.
Fertility and Sterility
REFERENCES 1. Semm K. New methods of pelviscopy (gynecologic laparoscopy) for myomectomy, ovariectomy, tubectomy and adnectomy. Endoscopy 1979;11: 85–93. 2. Rossetti A, Sizzi O, Chiarotti F, Florio G. Developments in techniques for laparoscopic myomectomy. JSLS 2007;11:34–40. 3. Sizzi O, Rossetti A, Malzoni M, Minelli L, La Grotta F, Soranna L, et al. Italian multicenter study on complications of laparoscopic myomectomy. J Minim Invasive Gynecol 2007;14:453–62. 4. Doridot V, Dubuisson JB, Chapron C, Fauconnier A, Babaki-Fard K. Recurrence of leiomyomata after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2001;8:495–500. 5. Hanafi M. Predictors of leiomyoma recurrence after myomectomy. Obstet Gynecol 2005;105:877–81.
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