Total

Vaginal Hysterectomy on Uterine Prolapse

with Huge Fibroid

Case Report
Introduction

Case
Fig. 1. Uterine fibroid Fig. 2. Uterine Prolapse

Discussion
• Pelvic organ prolapse with huge fibroid (intramural) was a rare
case.
• The treatment of this condition is hysterectomy and it can be
Conclusion performed by vaginally or abdominally.
• We reported a case total vaginal hysterectomy on uterine
prolapse with huge fibroid.
 Mrs. A, 54 yo. P3A0

Introduction Protrusion mass from vagina since 10 years before

admission.

• Initially the mass can push upward and getting bigger

Case when she stands and doing activity à now, the mass
cannot be pushed upward
• She already examined by gynecologist à uterine
Discussion fibroid and uterine prolapse à inserted vaginal ring
à expel spontaneously

Conclusion
 Physical examination
• Palpated solid mass 3 finger above symfisis and fixated.
• Inspection: there was bulging at anterior portio pushing down 7 cm
Introduction below the hymenal ring.
• Inspeculo exam. Inspeculo examination does not found any blood,
fluor or fluxus, portio was smooth, ostium’s closed, sondage 7 cm.
• From bimanual examination, uterus was palpated 3 finger above
Case symphisis, size ± 12 cm, no adnexal mass were palpated. Tonus
levator ani score was 2.

POP-Q
Discussion

Conclusion
Introduction

Case

Discussion

Conclusion
Ultrasound Exam
Found solid mass 106 x 91 mm
Multiple intramural uterine myoma
Adnexal adhesion
 Diagnosis
Introduction • Prolaps uterine grade IV,
• Cystocele grade III,
• Rectocele grade I,
Case • Elongatio Colli
• Multiple intramural uterine myoma

Discussion

Plan:
• Total vaginal hysterectomy
Conclusion • Colpocleisis
Introduction

Case Performed elips incision Uterine vessels were clamped,

cut, and suture

Discussion

Conclusion

Hemisection the cervix Intramyometrial coring Wedge morcelation

Introduction

Case

Discussion

Conclusion
Introduction

Case

Discussion

Conclusion
Introduction

Case

Discussion

Conclusion
 The decision regarding the technique for hysterectomy
Introduction in cases of fibroid, depends basically on the total
uterine volume or size.

Case The two most important considerations for vaginal

hysterectomy are vaginal access and uterine mobility.

Discussion
When the uterine size exceeds 12 weeks and/or volume
is greater than 250–300 cm3, experience in debulking
can help.
Conclusion
Introduction Uterus > 12 weeks size, uterus volume > 300 cm3,
slighly restricted uterine mobility are no longer
absolute contraindication for experienced surgeon.

Case
Wedge morcellation is the technique of choice for
grossly enlarge uteri and when coring or simple
Discussion hemisection fail.

Conclusion
Introduction
Vaginal hysterectomy can be performed for the removal of
enlarged uterine.

Case
Several techniques for dealing with benign uterine
enlargement are bisection, coring, morcellation and
myomectomy.
Discussion

Operator skill was one of the most important factors that uterine
prolapse and huge fibroid can be done by vaginal hysterectomy.

Conclusion
REFERENCES

1. Baird DD, Dunson DB, Hill MC, et al. High cumulative incidence of
uterine leiomyoma in black and white women: ultrasound
evidence. Am J Obstet Gynecol 2003; 188:100.
2. Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R.
Epidemiology of uterine fibroids: a systematic review. BJOG 2017;
124:1501.
3. Hoffman BL, et al. Pelvic organ prolpase. Williams Gynecology. 2nd
ed. New York: mc graw hill; 2012.
4. Sheth SS. Uterine Fibroids. In: Sheth SS, Studd JWW, eds. Vaginal
hysterectomy. London: Martin Dunitz Ltd., 2002, pp 79-94.
5. Magos A, Bournas N, SInha R, Richardson R, OConnor H. Vaginal
hysterectomy for the large uterus. British Journal of Obstetrics and
Gynecology. 1996;103:246–51.