|Year : 2014 | Volume
| Issue : 4 | Page : 202-203
A case of parasitic myoma 4 years after laparoscopic myomectomy
Osman Temizkan, Hakan Erenel, Bulent Arici, Osman Asicioglu
Department of Obstetrics and Gynecology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
|Date of Submission||19-Jul-2014|
|Date of Acceptance||23-Jul-2014|
|Date of Web Publication||23-Sep-2014|
Department of Obstetrics and Gynaecology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul
Source of Support: None, Conflict of Interest: None
We present a case of parasitic myoma complaining of abdominal pain, constipation, dyspareunia and dysmenorrhea 4 years after laparoscopic myomectomy. We performed laparoscopic myomectomy for multiple parasitic myomas. Three myomas were very firmly attached to bowel and mesentery. Parasitic myoma after laparoscopic surgery is very rare condition there are almost 35 cases in the literature. It is related with variable symptoms or can be asymptomatic. Laparoscopic surgeons should be aware of this situation, and further investigation should be made in case of suspicion. Surgery for parasitic myomas can be difficult in case of bowel and mesentery involvement and patient should be informed about the extensive surgery.
Keywords: Hysterectomy, laparoscopy, leiomyoma, leiomyomatosis, myoma, uterine myomectomy
|How to cite this article:|
Temizkan O, Erenel H, Arici B, Asicioglu O. A case of parasitic myoma 4 years after laparoscopic myomectomy
. J Min Access Surg 2014;10:202-3
| ¤ Introduction|| |
Uterine myomas are the most common female genital tumour and occur in ~25% of reproductive-aged women.  Uterine smooth muscle tumours with unusual growth patterns include leiomyosarcomas, parasitic leiomyomas, intravenous leiomyomatosis, disseminated peritoneal leiomyomatosis and benign metastasizing leiomyomas. Parasitic myomas were first described by Kelly and Cullen in 1909 and are rare pathologic structures thought to be pedunculated subserosal myomas that twist from the uterine pedicle and survive by neovascularisation of adjacent organs, such as the omentum and mesenteric vessels.  Parasitic myomas are very rare condition there are almost 40 cases in the literature. Here, we present a case of a patient with multiple parasitic myomas after laparoscopic surgery.
| ¤ Case report|| |
A 35-year-old nulligravida patient presented with progressive abdominal pain, constipation, dyspareunia and dysmenorrhea. She underwent laparoscopic myomectomy with electric tissue morcellation in 2009 due to a 9-cm subserosal fibroid of the fundus. On physical examination, there was no sign of an acute abdomen and a manuel examination palpated a 7-cm lobulated mass in the Douglas pouch. Transvaginal ultrasound revealed posterior 7-cm × 5-cm and anterior 4-cm × 3-cm heterogeneous masses in the uterus. Subserosal fibroids were also observed. Magnetic resonance imaging confirmed our findings. We planned a diagnostic laparoscopy and myomectomy for multiple fibroids. Upon laparoscopic exploration, we found two subserosal myomas on the anterior of the uterus, three subserosal myomas on the posterior of the uterus, one parasitic myoma with a 4-cm × 3-cm diameter on the peritoneum of bladder and a lobulated 7-cm × 5-cm parasitic myoma in the Douglas pouch [Figure 1]. In addition, three 4-cm myomas were firmly attached to sigmoid colon serosa and mesentery [Figure 2]. The largest fibroid was lobulated and firmly adhered to the rectum and was separated by mobilisation of the rectum using a rectal probe. All fibroids were retrieved by morcellation, and the peritoneal cavity was washed with isotonic saline. No post-operative complications were observed. Histopathology confirmed the masses as leiomyomas.
| ¤ Discussion|| |
Although uterine myomas are the most common female tumours, parasitic myomas are rare pathologic structures and their etiopathogenesis remains uncertain. Several mechanisms are have been proposed in the literature. One theory is that pedunculated subserosal myomas become separated from uterus and find a blood supply from another adjacent organ, such as the bowel, peritoneum, omentum or mesentery. 
Advances in laparoscopic surgery, energy modalities and retrieval systems have made laparoscopic myomectomy a frequently used procedure. A morcellator is generally used to retrieve myomas in small fragments, although a colpotomy or mini-laparotomy can be performed to retrieve intact myomas. During the removal of large fibroids by morcellation, small myoma fragments related to iatrogenic parasitic myomas may spread into the abdominal cavity. The first report describing a parasitic myoma after laparoscopic surgery was described in 1997.  In that case, a morcellator was not used, and the parasitic myoma was located near the trocar sleeve and had grown into the abdominal wall. However, in our case, there were seven parasitic myomas in various locations of the lower abdomen. This could be explained by the use of an electric morcellator and the scattering of small fragments during morcellation. The location of parasitic myomas is variable, but in the literature, they are commonly reported in the pelvic region.
A recent report showed a 1.2% incidence of parasitic myoma after laparoscopic myomectomy using morcellation.  The frequency of this condition is difficult to establish, because the diagnosis of small and asymptomatic parasitic myomas is difficult, and these myomas can be overlooked at follow-up. This questions the necessity of surgery, because small myomas in the mesentery and bowel wall can be attached very firmly to bowel, as was seen in our case. Patients should be informed about the extensive surgery in such cases. Non-surgical or medical treatment of patients with small, asymptomatic parasitic myomas could be an option. However, there are no reports addressing the treatment and clinical course of small, asymptomatic parasitic myomas. These concerns should be addressed in future prospective studies.
Parasitic myomas are a rare condition resulting from the small fibroid fragments remaining after morcellation, and they should be considered in patients that have undergone previous laparoscopic surgery and can be prevented using proper precautions during the procedures, including detailed inspection, repeated washing and aspiration of the abdominopelvic cavity.
| ¤ References|| |
|1.||Cramer SF, Patel A. The frequency of uterine leiomyomas. Am J Clin Pathol 1990;94:435-8. |
|2.||Kelly HA, Cullen TS. Myomata of the uterus. Philadelphia: WB Saunders; 1909. |
|3.||Brody S. Parasitic fibroid. Am J Obstet Gynecol 1953;65:1354-6. |
|4.||Ostrzenski A. Uterine leiomyoma particle growing in an abdominal-wall incision after laparoscopic retrieval. Obstet Gynecol 1997;89:853-4. |
|5.||Cucinella G, Granese R, Calagna G, Somigliana E, Perino A. Parasitic myomas after laparoscopic surgery: An emerging complication in the use of morcellator? Description of four cases. Fertil Steril 2011;96:e90-6. |
[Figure 1], [Figure 2]