Vaginal Myomectomy for Large Intracervical Fibroids in Women Desirous of Preserving Their Uterus: A Case Series

Cervical fibroids are rare, benign tumors. The treatment of uterine fibroids is well-established, with standard treatment guidelines in place; however, there remains a lack of consensus on a standardized approach for cervical fibroids. A small prolapsing fibroid polyp may be removed vaginally, and a hysteroscope can be used in such cases to identify and ligate the pedicle. However, large cervical fibroids present a surgical challenge. Myomectomy is the cornerstone for the surgical management of cervical fibroids in women who wish to preserve their uterus. An enlarged cervix alters the anatomy of adjacent vital structures like the ureters, bladder, rectum, and uterine vessels, increasing the risk of injury to these structures. Due to the narrow operating field and the potential for injury, preoperative catheterization of the ureters through double-J (DJ) stenting is performed to delineate their course prior to surgery. Here, we report a series of cases in which intracervical fibroids, visible vaginally as a cervical protuberance, were enucleated vaginally using Bonney's principles. The base of the fibroid was clamped and ligated, followed by obliteration of the space and reconstruction of the cervix. Injection of vasopressin was unavailable in our resource-limited hospital; therefore, adrenaline was injected in a 1:200,000 dilution into the fibroid capsule intraoperatively to minimize blood loss. This method of enucleation minimizes the risk of injury to adjacent organs since the dissection occurs intracapsularly. Preoperative prophylactic DJ stenting was also not needed. Despite the lack of advanced medical options to reduce fibroid size and vascularity, such as preoperative gonadotropin-releasing hormone (GnRH) analogues and uterine artery embolization, in our low-resource setting, our technique of vaginal myomectomy effectively managed the challenges presented by large intracervical fibroids while preserving fertility. The only limitation was that fibroids that were not palpable through the cervical lips could not be enucleated using this approach.