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Strategy for Laparoscopic Cervical

Myomectomy
Article in Journal of Minimally Invasive Gynecology March 2010
DOI: 10.1016/j.jmig.2009.12.020 Source: PubMed

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Original Article

Strategy for Laparoscopic Cervical Myomectomy

Shozo Matsuoka, MD*, Iwaho Kikuchi, MD, Mari Kitade, MD, Jun Kumakiri, MD,
Keiji Kuroda, MD, Sachiko Tokita, MD, Masako Kuroda, MD, and Satoru Takeda, MD
From the Department of Obstetrics and Gynecology, Juntendo University School of Medicine, Tokyo, Japan (all authors).

ABSTRACT Objective: Myoma of the uterine cervix is rare, accounting for about 5% of all myomas. Compared with myomas that occur in
the uterine corpus, cervical myomas are closer to other organs such as the bladder, ureter, and rectum, and the approach needs to
be modified because the organs that have to be considered differ depending on the location of the myoma. We divided cervical
myomas into 2 types according to location, comprising an intracervical type and extracervical types. A clear outline of surgical
treatment for cervical myoma has not described in previous papers. We then investigated the surgical strategy for these types.
Patients: Subjects comprised 16 patients who were diagnosed with cervical myoma in our hospital between January 2005 and
April 2009, and who underwent laparoscopic myomectomy.
Result: Mean operative time was 105.8643.2 (82.8-128.8) min, mean blood loss was 1056117 (42.6-167.4) ml, and mean
specimen weight was 208.36195.4 (99.3-306.2) g. Histopathological examination showed atypical myoma in 1 case and
leiomyoma in others.
Conclusions: 16 cases of cervical myomectomy were performed safely by developing a uniform strategy that uses a fixed operative procedure, even with laparotomy, if sufficient attention is paid to the following 6 points: 1) attempting to reduce the size
of the myoma with the use of preoperative GnRH; 2) determining the positional relationship between the myoma and surrounding organs; 3) temporarily blocking uterine artery blood flow with the use of vessel clips; 4) suppressing bleeding during myomectomy with the use of vasopressin; 5) minimizing the risk of damaging surrounding organs by positioning the incision in the
myometrium somewhat lateral to the uterine corpus; and 6) the bottom of the wound after enculation should be pulled up by the
forceps for suturing to avoid making dead space. Journal of Minimally Invasive Gynecology (2010) 17, 301305 2010
AAGL. All rights reserved.
Keywords:

Laparoscopy; Cervical myoma; Myomectomy; Uterine artery

Uterine myoma is one of the most common diseases in

women of reproductive age, occurring in 20% to 50% during
these years [1]. Myoma of the uterine cervix is rare, accounting
for about 5% of all myomas. Enlargement of the cervix causes
displacement of the position and course of the surrounding
organs of the bladder, ureter, and uterine blood vessels, and
surgical treatment is problematic in many cases. Surgical procedures used with uterine myomas include myomectomy and
total hysterectomy, but cases are seen in which advance
The authors have no commercial, proprietary, or financial interest in the
products or companies described in this article.
Corresponding author: Shozo Matsuoka, MD, Department of Obstetrics
and Gynecology, Juntendo University School of Medicine, Hongo, 2-1-1,
Bunkyo-ku, Tokyo, 113-8421.
E-mail: smatuoka@juntendo.ac.jp
Submitted October 15, 2009. Accepted for publication December 23, 2009.
Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ - see front matter 2010 AAGL. All rights reserved.
doi:10.1016/j.jmig.2009.12.020

myomectomy is needed even when total hysterectomy is to

be performed. Compared with myomas that occur in the uterine
corpus, cervical myomas are closer to other organs such as the
bladder, ureter, and rectum, and the approach needs to be modified since the organs that have to be considered differ depending on the location of the myoma. Takeuchi et al. have reported
a treatment method, which has been adopted in our hospital, for
pedunculated myomas of the uterine cervix that occur submucosally [2]. With reference to the report by Takeuchi et al. we
divided cervical myomas into 2 types according to location,
comprising an intracervical type and extracervical types. We
then investigated the surgical strategy for these types.
Patients
Sixteen patients diagnosed with cervical myoma in our
hospital between January 2005 and April 2009, and underwent laparoscopic myomectomy. Cervical myomas

Journal of Minimally Invasive Gynecology, Vol 17, No 3, May/June 2010

302
Table 1

Patient characteristics
No.

Age

CC

Type

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

31
40
41
39
30
37
40
36
40
37
38
39
38
45
30
37

0
0
0
2
0
0
0
0
3
0
2
0
0
1
0
0

0
0
0
2
0
0
0
0
2
0
2
0
0
0
0
0

Hypermenorrhea
Hypermenorrhea
Hypermenorrhea
Hypermenorrhea
Hypermenorrhea
Pressure symptom
Lumbago
Hypermenorrhea
No
Pressure symptom
Hypermenorrhea
Sterility
Hypermenorrhea
Sterility
No
Pressure symptom

IC
IC
IC
IC
IC
EC
EC
EC
EC
EC
EC
EC
EC
EC
EC
EC

diagnosed by preoperative magnetic resonance imaging

(MRI) were classified into 2 locations: intracervical (IC); extracervical (EC) (Fig. 1).
Mean age of patients was 37.3 6 4.2 (35.2-39.6) years.
Five patients were IC type, 11 were EC type. Four patients
were multiparous and 7 were nulliparous. Eight patients
had hypermenorrhea, 3 showed pressure symptoms of the
lower abdomen, 2 were infertile, and 1 had low back pain.
Mean maximum diameter of the myoma according to MRI
was 6.9 6 1.6 (6.0-7.8) cm, and all patients had received
gonadotropin-releasing hormone (GnRH) analog for 3 to 6
months before surgery (Table 1).
Surgical Technique
We performed all surgeries under general anesthesia by endotracheal intubation in the lithotomy position. Pneumoperitoneum was applied by closed method from under the umbilical
region and an 11-mm trocar was inserted in the umbilical

region for the laparoscope. A 5-mm trocar was inserted on

both sides of the lower abdominal region and a 12-mm trocar
was inserted in the left upper abdominal region (2 cm above the
umbilical region along the anterior axillary line) [3]. Uterus
was handled by uterine manipulating device (Uterine manipulator; Ethicon Endo-Surgery). intracervical type [2].
In the intracervical type, the cervix was dilated by Hegar
cervical dilators (nos. 1 to 10). The uterus was anteflexed
by lowering a Hegar dilator inserted into the urine cavity. Vasopressin 20 IU in 1 mL was diluted 100 times with saline solution. Vasopressin 5 to 8 units was laparoscopically injected
into the posterior cervix. The laparoscopic appearance is
shown in Fig. 2A. A longitudinal incision of about 5 cm
was made with a monopolar needle electrode (Probe Plus
II; Ethicon, Tokyo Japan) up to the interior cervical canal,
which was expanded with the Hegar dilator (Fig. 2B), and tumor adhesion areas were cut with the monopolar electrode
under direct vision. The stalk of the myoma was ligated
and cut with 2/0 Polysorb (Tyco Healthcare Japan, Tokyo,
Japan) (Fig. 3C). For the first layer, the cervical canal mucosa
was sutured at intervals of about 1 cm with 2/0 Polysorb. To
ensure a visual field during surgery, suture ligatures were
made from the lateral side. For the second layer, continuous
sutures of the muscle layer were made with 2/0 Polysorb. The
peritoneum was closed with suture made by use of 3/0 Polysorb) (Fig. 2D).

Extracervical Type
In the presence of a posterior uterine wall myoma, the
course of the ureter was confirmed, with special attention to
the sacral uterine ligament attachments, to determine displacement in the relative position of uterine arteries or ureter.
At times when the myoma was large and boundaries difficult
to confirm, the broad ligament was opened with an anterior
approach to delineate the myoma. In case of an anterior wall

Fig. 1. Preoperative magnetic resonance imaging findings (T2 sagittal). (A) Intracervical type. (B) Extracervical type (anterior uterine wall). (C) Extracervical
type (posterior uterine wall). Arrow 5 myoma nuclei.

Matsuoka et al.

Laparoscopic Cervical Myomectomy

303

Fig. 2. Laparoscopic myomectomy findings (intracervical type). (A) Laparoscopic findings of intracervical-type myoma. (B) Longitudinal incision made with
a monopolar electrode in the posterior uterine wall. (C) Cutting the stalk of the myoma. Arrow 5 stalk of myoma. (D) Suture closure of the endometrium and
muscle layer with 2/0 Polysorb.

type, a transverse incision was made in the uterovesical pouch

and peritoneum, and inferior blunt dissection of the bladder
was performed (Fig. 3A).
In cases where a great deal of bleeding was expected, the
broad ligament was opened and the uterine artery was clipped
with a vessel clip (Endo Clip; Tyco Healthcare Japan). The
uterine artery was identified by following it back from the internal iliac artery or lateral umbilical ligament (Fig. 3B).
Local injection of vasopressin diluted 100 times was given
and a transverse incision was made in the uterine wall just before the apex of the myoma (Fig. 3C). When performing traction and enucleation with a laparoscopic myomectomy
screw, the base of the wound was held with grasping
forceps, and suturing to stop the bleeding was done with
0 Polysorb (Tyco Healthcare Japan). Cases were encountered
with upward pressure on the anterior or posterior vaginal fornix from the myoma, in which the vaginal wall was released
as a result of myomectomy. In such cases, suture closure of
the vaginal wall was performed with 2/0 Polysorb from the
peritoneal side. Continuous sutures of 2 to 3 layers were
made in the myometrium with 0 Polysorb, and Vessel clips
were removed when clipping of the uterine artery had been
performed. The broad ligament was closed with 2/0 Polysorb
continuous sutures.

Results
Mean operative time was 105.8 6 43.2 (82.8-128.8) minutes, mean blood loss was 105 6 117 (42.6-167.4) mL, and
mean specimen weight was 208.3 6 195.4 (99.3-306.2) g
(Table 2). The uterine artery was clipped in 7 cases, but no
transfusion was conducted in any cases. All patients were discharged by the third day after surgery. There was no postoperative complication. One patient desirous of fertility is
pregnant at this point. Histopathologic examination showed
atypical myoma in 1 case and leiomyoma in others. Hypermenorrhea began to improve from the first menstruation after
the operation and no increase in menstrual amount has been
noted in the course observation period, to 4 years.
Discussion
With advances in assisted reproductive technology and
with women becoming pregnant at older ages, there is an increasing need for myomectomy as a treatment for uterine
myoma. Compared with open abdominal surgery, less postoperative adhesion and better prognosis for pregnancy is
seen after laparoscopic surgery. Laparoscopic surgery is
thus a better option for patients undergoing myomectomy

Journal of Minimally Invasive Gynecology, Vol 17, No 3, May/June 2010

304

Fig. 3. Laparoscopic myomectomy findings (extracervical type). (A) Laparoscopic findings. BL 5 Bladder; M 5 myoma. (B) Opening of the broad ligament,
exposure of the left uterine artery, and clipping with a vessel clip. (C) Traction and enucleation of the myoma with a laparoscopic myomectomy screw.

who still desire to become pregnant [4]. Conversely, enucleation, suture, and recovery of myomas with laparotomy
require a certain degree of skill and are restricted by the
size and location of the tumor. Until now, open or laparoscopic total hysterectomy has been conducted for patients
with no desire to have children. For women who desired to
have children, particularly in cases when the myoma was
large, open myomectomy or surgery that combined uterine
artery ligation and laparoscopic myomectomy was performed
because of the possibility of significant bleeding [5].
However, although no difference was seen in the recurrence

rate with open myomectomy or laparoscopic myomectomy,

more intraabdominal adhesions tend to be seen with open
myomectomy than with laparoscopic myomectomy, and
there has been concern about the effects of this on postoperative pregnancy rates [6]. Combined uterine artery embolization and myomectomy is believed to be effective with regard
to intraoperative bleeding and postoperative menstrual blood
loss, but there has been insufficient investigation on the
effects on postoperative sterility and pregnancy [7]. It is difficult to conclude that this procedure is indicated for women
who desire to become pregnant. In recent years a method has

Table 2

Surgical outcome
No.

Type

Size (cm)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

IC
IC
IC
IC
IC
EC
EC
EC
EC
EC
EC
EC
EC
EC
EC
EC

5!3!2
7!4!5
4!3!4
8!5!7
4!5!5
6!4!5
6!7!8
6!7!6
5!3!4
9!7!8
10 ! 9 ! 10
6!7!7
9!7!6
7!5!6
6!4!4
7!6!7

UA clipping

1
1
1
1
1

Operative
duration (min)

Blood loss (g)

Weight
of specimen (g)

Location
of myoma

70
97
48
75
85
115
200
90
68
185
150
95
135
125
70
85

20
10
10
20
30
300
300
115
30
250
150
100
300
20
20
5

20
90
18
120
150
116.5
486
375
65
510
640
228
200
25
80.4
120

SM
SM
SM
SM
SM
IM
IM
IM
IM
IM
IM
SS
SS
IM
IM
IM

IC 5 Intracervical myoma; EC 5 extracervical myoma; UA 5 uterine artery clipping; SM 5 submucous; IM 5 intramyometrium; SS 5 subserous.

Matsuoka et al.

Laparoscopic Cervical Myomectomy

been reported to temporarily embolize the uterine artery with

use of an endovascular balloon occlusion catheter [8], but this
procedure has not yet come into general use. Using this strategy, laparoscopic myomectomy can be performed safely
without the use of open myomectomy or interventional angiography.
Preoperative administration of GnRH for 3-4 months can
reportedly reduce the size and volume of the uterus,
improve preoperative hemoglobin levels, and effectively reduce operative time and period of hospitalization [9]. Conversely, recurrence rate also apparently increases in cases of
multiple myoma [10]. However, in cases when a visual field
is difficult to ensure, such as with myoma of the cervix, the
difficulty of surgery is greatly lessened by reducing myoma
size. Reducing the size of the myoma is therefore considered necessary.
Clipping of the uterine artery results in less need for angiography than with uterine artery embolization or an occlusion
catheter. Moreover, unlike uterine artery embolization, blood
flow can be reopened. Clipping is therefore effective in
controlling the amount of blood loss in the many patients
with myoma who desire to have children.
Similarly, with local administration of vasopressin, blood
flow around the myoma is blocked from the vasoconstrictor
action of vasopressin and the resistance index of the uterine
artery is increased [11]. This decreases bleeding during suturing, making this a very effective way to simplify the surgical
procedure.
The most difficult part of cervical myomectomy is suturing the base of the wound following enucleation. Complete
dissection of surrounding organs such as the bladder and ureter near the base of the wound is difficult. Bleeding makes the
visual field hard to maintain, thereby increasing the possibility of damage during suturing. A bottom-up procedure makes
it possible to perform suturing safely by providing a complete
visual field.
Surgery for cervical myoma is said to be more difficult
than that for myomas of the uterine corpus, because of the anatomic location and displacement of surrounding organs.
However, after considering the location of myoma, cervical
myomectomy can be performed safely by developing a uniform strategy that uses a fixed operative procedure, even
with laparotomy, if sufficient attention is paid to the following 6 points: (1) attempting to reduce the size of the myoma
with the use of preoperative GnRH; (2) determining the
positional relationship between the myoma and surrounding

View publication stats

305

organs; (3) temporarily blocking uterine artery blood flow

with the use of vessel clips; (4) suppressing bleeding during
myomectomy with the use of vasopressin; (5) minimizing the
risk of damaging surrounding organs by positioning the incision in the myometrium somewhat lateral to the uterine corpus; and (6) the bottom of the wound after enculation should
be pulled up by the forceps for suturing to avoid making dead
space.

Supplementary data
Supplementary data associated with this article can be
found, in the online version, at doi:10.1016/j.jmig.2009.12.
020.
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