Hello! Today we want to tell you about a case of a patient who came from the United States, where they wanted to remove her uterus due to a diagnosis of fibroids. Remember that knowledge is power and a good diagnosis is essential to propose the correct treatment.

Our patient is 38 years old, has no children, has a desire for fertility, and had symptoms such as pain and genital bleeding. She went to her consultation with her doctor in the United States who diagnosed her with uterine fibroids and they suggested performing a hysterectomy since she had 5 fibroids… If you want to have children, then obviously that is not an alternative. She had access to our videos on YouTube and thus decided to make a consultation by video call, we discussed the case, she showed me the images, she sent me the information and yes, we confirmed the presence of the fibroids. We explained everything we had done previously and made the decision to perform the fibroid surgery, so she moved, went to Creafam Veracruz where we did a first clinical evaluation, when we saw her in the office we not only confirmed the presence of fibroids, when performing a vaginal ultrasound I observed an intracavitary image, so I decided to perform other types of diagnostic tests such as hysterosonography. The hysterosonography allowed me to diagnose the presence of an endometrial polyp that had not been seen in the United States.

When we do a hysterosonography we place a small catheter inside the cervix and through it we can pass fluid, we pass physiological solution and then we perform an ultrasound vaginally with the fluid inside the uterus. If we have the uterine cavity filled with fluid we can better define the internal contour of the cavity and in this way we can see more accurately the presence of polyps or submucosal fibroids. Then the liquid allowed us to see that there was a protuberance inside the cavity and in this way I confirmed the diagnosis of the polyp, so this is important because polyps also generate sacs and when they are very large, obviously the problem will continue to worsen. So our patient had already diagnosed uterine fibroids but also an endometrial polyp, which implies a different surgical approach.

Our patient’s fibroids were mainly intramural and subserosal. Intramural fibroids can contribute to bleeding but subserosal fibroids cannot, so the bleeding symptoms that I already had were surely more related to polyps than to fibroids, so making a good diagnosis was essential to solve the problem. So like, if we have two problems, how do we address it? On the same day of surgery, with the same anesthesia event that was epidural, with a regional block, we first performed hysteroscopy and then open surgery to resect the fibroids. When we do hysteroscopy or the vaginal approach, the hysteroscope enters through the cervical canal, in this way we can observe all the clinical aspects of the cavity under direct vision with the camera. We identify the uterine ostia, we see the entire cavity, the entire anterior wall, posterior wall, and bottom of the uterine cavity.

Our patient’s polyp was implanted in the lateral wall and thus pedunculated because it ended up occupying practically the entire space of the uterine cavity. Next, through the same hysteroscope, as it has a surgical shirt, a small scissors are introduced and with the scissors we cut the base of the polyp, in this way we detach it, we separate it from the uterine cavity. So this first, let’s say, surgical approach, allowed us to solve the patient’s first problem, which was to remove the polyp that was the main source of the bleeding that she presented. Once the polypectomy has been performed, we remove all the hysteroscope, all the equipment, we change the patient’s position and then we proceed to do the second part of the surgery, which is abdominal surgery. Then all the cleaning is done, all the corresponding surgical preparation, we make the abdominal incision and then we identify the uterus, we identify the fibroids. Our patient had two types of fibroids: intramural fibroids and subserosal fibroids. Then, as we have done on other occasions, we proceeded to approach them one by one.

The idea of addressing each fibroid individually is to have, above all, a very careful surgical technique. Remember that the main objective is to preserve the uterus, so we proceed to resect each fibroid individually. Intramural fibroids were not so deep as to deform the cavity, however, it is known that intramural fibroids as they grow… As they prevent normal fibers from being compressed, they can also cause bleeding. An interesting characteristic that we observed was that when performing the hysteroscopy and observing the fundus of the uterus, it was seen that one of the intramural fibroids was already beginning to press on the cavity. What advantages did it offer us to have performed the hysteroscopy first? Having this diagnosis, we were more careful in the abdominal approach since we knew that one of the intramural fibroids was a little deeper. So it is not only about locating it, it was also about removing it without incising the uterine cavity. Because? Because if I remove the fibroid and I am not careful and open the uterine cavity, repairing the cavity can generate a long-term problem and that is that intracavitary adhesion will form due to the suture, that is, once the uterus recovers they will There may be intrauterine synechiae, so if synechiae are generated inside the cavity, we end up having a problem in the future when trying to get pregnant.

So, in summary, what did we do? First by hysteroscopy we confirmed the diagnosis of the polyp, we removed it, we identified that one of the intramural fibroids was already beginning to put pressure on the cavity and then with the abdominal approach we removed the rest of the intramural and subserosal fibroids, taking great care in the myoma that was in the uterine fundus pronouncing towards the cavity.

The patient, ten days after the surgery, was fit to travel, she left for the United States, we have already written to each other a couple of times to follow up on how her postoperative period has been. She told me that she feels very well, Clinically, she has been perfect, she already has a normal life and the next step will be in a few months to start talking or planning the reproductive issue. There are times when we can seek pregnancy without performing myomectomies, without resecting the fibroids, and we have a video of another patient who came from the United States on whom we performed in vitro fertilization without having removed the fibroids… It all depends on having a good diagnosis to evaluate to what extent the uterine cavity is compromised, which is ultimately the place where the pregnancy is going to implant. In this case of our patient, we had two problems: the polyp and one of the fibroids that was already beginning to put pressure on the cavity, so the strategy is to solve the uterine pathology to later search for pregnancy.

It is very likely that due to the patient’s age and other history, she may need to resort to in vitro fertilization, but it is an issue that will be addressed later, knowing that she has a uterine cavity that is in a position to seek pregnancy. Remember that knowledge is success and at Creafam we have all the strategies to help you achieve your dreams.

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