Encountering Endometriosis During Planned Myomectomy

INTRODUCTION: Endometriosis and fibroids commonly present together. In this video, we review the signs and symptoms that indicate endometriosis is likely present in patients with fibroids. We review a surgical case of a planned myomectomy during which endometriosis was identified intraoperatively in order to demonstrate these points. This case illustrates the importance of surgical planning and patient counseling prior to myomectomy when concomitant endometriosis is suspected. OBJECTIVE: To review incidence, symptoms, and presentation of endometriosis and fibroids. To highlight risk factors for concurrent endometriosis in patients with fibroids. To review techniques for endometriosis surgery and tips for optimizing surgical planning and outcomes in patients with concurrent disease. METHODS: 25-year-old G0 female who presented with 8 months of severe pelvic pain, heavy menstrual bleeding, and uterine retroversion. Subsequent MRI showed 4-cm FIGO Type 7 fibroid on the posterior uterine body. Surgical footage is used to demonstrate educational objectives during robotic-assisted laparoscopic myomectomy and excision of endometriosis. RESULTS: During scheduled myomectomy, stage IV endometriosis was noted with significant pelvic adhesive disease between the posterior uterus, fibroid, and adnexa. The fibroid was found to contain pockets of chocolate fluid. Additionally, adhesions and tethering of the rectosigmoid colon, mild bilateral hydrosalpinx, and an obliterated posterior cul-de-sac were also noted. Lysis of adhesions was performed to restore anatomy prior to myomectomy. Following myomectomy, complete excision of endometriosis was performed involving retroperitoneal dissection, ureterolysis, peritonectomy, and excision of deep endometriosis nodules. CONCLUSIONS: Symptomatology and exam findings of fibroids may obscure diagnosis of endometriosis. Concomitant endometriosis should be suspected in young, nulliparous patients with severe pelvic pain exacerbated by menstrual cycles and those with central sensitization. In these patients, MRI imaging with IV and rectovaginal contrast gel is recommended for surgical planning. The presence of heterogeneous lesions or T1 hyperintense cystic foci within or involving the myometrium or myomas may be indicative of endometriosis, adenomyosis, or localized adenomyoma. Surgical planning and counseling should be modified accordingly.