Vaginal Myomectomy Through an Anterior Colpotomy

Abstract

Objectives: This article is a presentation of a practicable alternative to laparotomy or laparoscopy for removal of a symptomatic anterior uterine leiomyomata.Methods: A 34-year-old nulligravida with a 1-year history of dyspareunia and urinary frequency was evaluated in the gynecology clinic. Evaluation revealed a subserosal myoma in the anterior uterine wall. The patient desired removal of the myoma and preservation of future fertility. Based on the size and location of the myoma, a vaginal approach through an anterior colpotomy under spinal anesthesia was the selected procedure.Results: Vaginal myomectomy of a 7 ؋ 3.5 ؋ 3-cm, 54-g myoma was performed through a transverse anterior colpotomy incision under spinal anesthesia. Before the colpotomy incision, 15 mL of 1% lidocaine/1:200,000 epinephrine solution was injected into the paracervical and vesicouterine tissue. After the colpotomy, an additional 10 mL was infiltrated into the myometrium surrounding the myoma for vasoconstriction. Enucleation of the myoma using sharp and blunt dissection was relatively bloodless. Repair of the uterus in layers and closure of the colpotomy was achieved using number 0 polyglycolic acid sutures. The patient was discharged to home directly from the recovery room. Her postoperative course was benign and the abnormal symptoms entirely resolved. Conclusion:Myomectomy for symptomatic leiomyomata in patients desiring fertility preservation is usually performed through a laparotomy or by operative laparoscopy. Pedunculated endometrial or small submucosal myomas are best removed using operative hysteroscopy. When anterior uterine subserosal or intramural myomas are diagnosed, vaginal myomectomy using an anterior colpotomy approach under conduction anesthesia and lidocaine with an epinephrine "liquid tourniquet" may be a viable alternative in selected patients, as demonstrated in this case report.Key Words: vaginal myomectomy, myomectomy through a colpotomy incision, minimally invasive myomectomy (J Pelvic Med Surg 2005;11:145-147) L eiomyomata are the most common uterine neoplasms found in women, reportedly occurring in 20% to 25% of women of childbearing age. 1,2 Symptoms of leiomyomata include menstrual abnormalities, dysmenorrhea, dyspareunia, pelvic pain or pressure, urinary and defecation abnormalities, infertility, and miscarriage. 1,3 In symptomatic women who have completed their childbearing, or do not desire future fertility, hysterectomy is the definitive therapeutic option. When future fertility is desired, hormonal therapy to include short-term gonadotropinreleasing hormone agonists or uterus-conserving myomectomy is usually the selected therapy. Traditionally, laparotomy was the method of choice, whereas operative laparoscopy and recently hysteroscopic myomectomy techniques have been successful in excising uterine myomas of limited size and location. 1,2,5 Laparoscopy requires general anesthesia and multiple small abdominal incisions, and assumes potential risks associated with general anesthesia and laparoscopic surger...