Techniques for Vaginally Managing Prolapsed Uterine Fibroids

INTRODUCTION: Prolapsed submucosal fibroids are found in 2.5% of patients. Removal via a vaginal approach is the most minimally invasive approach and is the recommended initial treatment. Challenges to a vaginal myomectomy include adequate visualization and the risk of bleeding from the myoma stalk. OBJECTIVE: The purpose of this video is to review techniques for vaginally managing prolapsed uterine fibroids. Tips for improved visualization and improved hemostasis are discussed. METHODS: This is a video compilation of two vaginal myomectomies performed in the operating room in an academic center. RESULTS: Techniques for improved visualization include utilizing appropriate retractors and downward traction on the prolapsed fibroid. Vaginal morcellation can also decrease the presenting size of the fibroid allowing for improved visualization of the fibroid stalk. Techniques for improved hemostasis include medical pretreatment with tranexamic acid. Suture ligation can be performed with the endoloop. Cautery with a bipolar loop or monopolar energy are also effective options. CONCLUSIONS: The vaginal approach is a safe, efficient, and effective route for managing prolapsed pedunculated uterine fibroids. There are multiple techniques to improve success rates by improving visualization and improving hemostasis.