Cervical stump leiomyomata after supracervical hysterectomy; a case report with review of literature

Cervical stump leiomyomata after supracervical hysterectomy; a case report with review of literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Cervical stump leiomyomata after supracervical hysterectomy; a case report with review of literature Ahmed Shoukry, Mahmoud Yousri This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4258070/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Sep, 2024 Read the published version in BMC Women's Health → Version 1 posted 24 You are reading this latest preprint version Abstract Background Despite being highly debated issue, subtotal or supracervical hysterectomy is still considered a safe and effective treatment for women with multiple fibroid uterus. Many lesions could arise on top of the preserved cervical stump such as recurrence of fibroids, cervical polyps, endometriosis, or malignancies which may necessitate reoperation and resection of the cervical stump or trachelectomy. Trachelectomy is known to be a difficult surgical procedure that may be associated with significant intra and post-operative morbidity. Case presentation: We presented here a case with a pelvic mass related to the cervical stump presented 8 years after subtotal hysterectomy. She complained of pelvic pain and vaginal discharge and spotting. Transvaginal sonography and magnetic resonance imaging were performed and a heterogeneous pelvic mass was revealed. Surgical exploration and resection of the mass with cervical stump excision was performed. Histopathology conformed the diagnosis of cervical stump multiple leiomyomata. Conclusion Supracervical or subtotal hysterectomy could be performed in selected women with appropriate counselling, mainly in cases of multiple leiomyomata and the selected candidate should be told about the potential of recurrent fibroids in the retained cervical stump and its consequences including the need for reoperation for cervical stump resection. Subtotal Supracervical Hysterectomy Fibroids Figures Figure 1 Figure 2 Background Hysterectomy is the most frequently used surgical procedure for women with symptomatic uterine fibroids.(1, 2) Preservation of the cervix uteri during a hysterectomy is a highly debated issue. Some of the potential benefits of supracervical hysterectomy (SCH) that proponents often mention are reduced blood loss, a shorter hospital stay, fewer intraoperative risks, less urinary manifestations, and better pelvic support(3–5). Although postoperative sexual function is presumed to be more satisfactory after SCH (6, 7), it was not found to be superior to a total hysterectomy (TH).(8–10) On the contrary, some problems have been often described with SCH as cyclic bleeding, pelvic pain, and a higher incidence of cervical disease(11). Cervical stump leiomyomas, cysts, cervical prolapse, endometriosis, precancerous lesions, and stump carcinoma are among the morbidities that may develop in the retained cervical stump. The literature indicates that the prevalence of cervical stump carcinoma is about 2–9% of all cervical carcinomas (12, 13). Additionally, leiomyosarcoma is an extraordinary rare lesion that may arise in the cervical stump following a SCH.(14) Among the commonest clinical indications for surgical excision of the cervical stump following supracervical hysterectomy are pelvic masses and vaginal bleeding(15). It has been cited that fibroids are the most common – in approximately 35% – pathology found in the excised cervical stump (16). We report a case of a large stump fibroid after a subtotal abdominal hysterectomy. Case report A 41-year-old nulliparous woman, presented with pelvic pain and offensive vaginal discharge with occasional vaginal spotting. Her past history is significant for four times of abdominal myomectomies for recurrent fibroid uterus, last one was 10 years ago. Two years after that, she underwent a subtotal abdominal hysterectomy with preservation of the ovaries also due to recurrent leiomyomas after myomectomy, operative specimen examination revealed a 2500-gm uterus with multiple interstitial and subserous leiomyomata ranging from 2–9.5 cm, histopathological examination confirmed the diagnosis of typical leiomyoma pathological features with no atypical or mitotic figures. All the surgeries were performed via vertical midline incisions. Her medical history is irrelevant expect for mild bronchial asthma controlled with periodic beta-agonist inhalers. On examination, her abdomen is lax, non-tender, with no palpable masses. Speculum examination revealed normal looking cervix with a well-estrogenized vagina. By bimanual examination, a firm, non-tender, pelvic mass was appreciated that has a limited mobility conjugated with movement of the cervix. A transvaginal ultrasound revealed a heterogeneous, irregular pelvic mass, giving the picture of degenerated fibroids measuring 10.2x7.6x6.5 cm encroaching on the right adnexa, with normal appearance of the left ovary. The mass looks suspicious for malignancy so a confirmatory magnetic resonance imaging (MRI) with IV gadolinium contrast was performed - demonstrated in figure (1) - showed heterogeneous T2 lobulated mixed solid and cystic lesion showing mainly hypo-intense signal in T2 and T1 weighted image epicentered upon the cervical stump and engulfing the right adnexa. Patient was counselled for exploratory laparotomy and resection of the mass. Figure (1) Sagittal T2W image showing ( A ) the remaining cervical stump with its endometrial lining and ( B ) heterogeneous lobulated mainly hypo-intense solid lesion showing areas of cystic changes consistent with cervical leiomyomata. Surgical details An extended lower midline incision was opted for to optimize exposure as well as to allow exploration of the entire abdominal cavity. Upon entry of the abdomen, a large pelvi-abdominal mass was noticed, which was entirely covered by densely adherent bowel posteriorly, and an exceptionally high bladder anteriorly. A lateral approach, opening and utilizing the retroperitoneal avascular pelvic spaces, was used to properly identify the borders of the mass and secure important adjacent structures, namely the ureters, iliac vessels, and recto-sigmoid. Development of the para-vesical and para-rectal spaces bilaterally, facilitated identification of the ureters and iliac vessels, followed by ureterolysis and lateralization of both ureters. Dissection of the densely adherent recto-sigmoid off the back of the mass with development of the rectovaginal space and identification of uterosacral ligaments. Decision was made to excise the fibroids off the cervical stump to optimize exposure of the cervical stump and allow for safe trachelectomy procedure Excision of the cervical stump using a retrograde approach after anterior colpotomy, allowing for preservation of maximal vaginal length. Suturing of the vaginal cuff in a single layer of continues suture fashion. Figures (2) illustrates the surgical specimen showing the excised cervix harboring multiple leiomyomata. Figure (2) showing the surgical specimen, the largest leiomyomata were excised first to facilitate resection of the cervical stump. The patient’s postoperative course was uneventful and she was discharged after 5 days. Pathological examination of the specimen confirmed the diagnosis of multiple leiomyomata of the cervical stump with marked hyaline, mucoid, and cystic degeneration. Discussion One of the simplest and most successful treatments for fibroids, adenomyosis, and functional uterine bleeding is hysterectomy. Total hysterectomy and subtotal or supracervical hysterectomy are two categories of hysterectomy based on the extent of operation (17). Bland (1925) defined the subtotal or supracervical hysterectomy as "one of the safest major operations performed within the abdomen cavity." (18). During this era with no access to antibiotics and blood transfusion, SCH was much preferred to TH as it was reported that TH associated with a significantly higher complication rate including mortality (19, 20). Nowadays, SCH contributes to only a very small percentage of all hysterectomies (20, 21). Conservation of the cervix with hysterectomy is associated with increased risk of cervical diseases such as polyps, fibroids, endometriosis, cysts, premalignant, and cervical malignancies which may develop many years after hysterectomy. It was reported that after SCH, 7–20% of women may suffer from problematic periodic bleeding that could necessitate cervical stump resection (12). According to data from the ACOG, 23 percent of women needed to be reoperated at least 14 months after their first surgery in order to have their cervical stump removed, and 1.5% of patients needed a second procedure to remove the cervical stump less than three months after their initial subtotal hysterectomy (22). In the study of Okaro et al, they reported that women who underwent supracervical hysterectomy have approximately 23% risk of trachelectomy (23). The most commonly cited indication for cervical stump resection in the published literature is cervical prolapse followed by pelvic mass/vaginal bleeding (24–27) Fibroids have always been described as the “recurring disease”. After myomectomy there are variable reported rates of recurrence include 12–15%, 31–43%, 51–62%, and 84% at 1, 3, 5, and 8 years respectively (28–33) and approximately 10–21% of women will undergo a hysterectomy within 5–10 years of myomectomy (32, 34). Recurrence of fibroids has been also described after hysterectomy (2, 35, 36), also the case presented here demonstrates that cervical stump may give rise to leiomyomatous growth. In a retrospective analysis of 137 patients underwent cervical stump resection after SCH, Neis F., et al reported that 3.7% of these patients have fibroids in their cervical stumps (27). Similarly, fibroids were found in 2 patients underwent cervical stumpectomy after SCH in a cohort of 309 patients reported by Hilger et al (24). There are many explanations for myomas recurrence after hysterectomy such as microscopic or macroscopic remaining fibroid remnants, rapture of leiomyoma capsule leading to seeding, lymphovascular spread, myoma morcellation, and mesothelial mesenchyme metaplasia (2). In cases of fibroid recurrence post SCH, it is mainly attributed to either microscopic cervical fibroid that grow after excision of the uterine corpus, leiomyomatous residuals – either micro or macroscopic – in the cervical surgical margin, or rarely due to de novo growth of a cervical fibroid. It is noted that the majority of leiomyomatous recurrence after subtotal hysterectomy occur when ovarian preservation is carried out at time of hysterectomy, as also in our presented case. Cervical stump leiomyomata are usually of a great concern because they often need surgical treatment as myomectomy or trachelectomy which may lead to significant surgical morbidity mainly bladder, ureteric, or bowel injury. Also the possibility of malignant disease is another issue as leiomyosarcoma has been reported in the cervical stump after subtotal hysterectomy (37). Both abdominal – whether laparoscopic or open – and vaginal routes are described for cervical stump resection, vaginal approach is cited with a lower complication rate (27%) versus 43% in the abdominal approach (24, 38). In a recent series of 137 cases of stump resection, the vaginal route was used in 75% of patients (27). Limitations to the vaginal approach are the existence of a suspected adnexal tumor or cervical malignancy. The requirement for simultaneous pelvic exploration in order to evaluate associated chronic pelvic pain, remove endometriosis, or both, would additionally require a non-vaginal route as laparoscopy (15). Vaginal approach is the preferred route especially in cases of cervical prolapse after SCH. Conclusion Supracervical or subtotal hysterectomy could be performed in selected women with appropriate counselling, mainly in cases of multiple leiomyomata and the selected candidate should be told about the potential of recurrent fibroids in the retained cervical stump and its consequences including the need for reoperation for cervical stump resection. Abbreviations SCH supracervical hysterectomy TH total hysterectomy MRI magnetic resonance imaging ACOG American College of Obstetrics and Gynecology Declarations Acknowledgments The authors thank the surgical and anesthesia team of Shatby Women University Hospital where the surgery was performed. Author contributions AS was the main surgeon and wrote the manuscript. MS was the main surgical assistant, read, revised, and approved the final manuscript. Funding The authors have received no external funding. Availability of data All data for the case report are available in this manuscript upon reasonable request. Conflict of interests The author declared that they have no competing interests. Consent to publish A written consent was obtained from the patient for publication of this case report. References Whiteman MK, Hillis SD, Jamieson DJ, Morrow B, Podgornik MN, Brett KM, et al. Inpatient hysterectomy surveillance in the United States, 2000–2004. American journal of obstetrics and gynecology. 2008;198(1):34. e1-. e7. Chu CM, Acholonu Jr UC, Chang-Jackson S-CR, Nezhat FR. Leiomyoma recurrent at the cervical stump: report of two cases. Journal of Minimally Invasive Gynecology. 2012;19(1):131-3. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I. Outcomes after total versus subtotal abdominal hysterectomy. New England journal of medicine. 2002;347(17):1318-25. Alkatout I, Mazidimoradi A, Günther V, Salehiniya H, Allahqoli L. Total or Subtotal Hysterectomy for the Treatment of Endometriosis: A Review. Journal of Clinical Medicine. 2023;12(11):3697. Dallas K, Taich L, Kuhlmann P, Rogo-Gupta L, Eilber K, Anger JT, et al. Supracervical hysterectomy is protective against mesh complications after minimally invasive abdominal sacrocolpopexy: a population-based cohort study of 12,189 patients. The Journal of Urology. 2022;207(3):669 − 76. Kilkku P, Grönroos M, Hirvonen T, Rauramo L. Supra vaginal uterine amputation vs. hysterectomy: Effects on libido and orgasm. Acta obstetricia et gynecologica scandinavica. 1983;62(2):147 − 52. Martins FE, Cassim F, Yatsina O, Adlam J. Female sexual dysfunction. Female Genitourinary and Pelvic Floor Reconstruction: Springer; 2023. p. 959 − 93. Anchan RM, Spies JB, Zhang S, Wojdyla D, Bortoletto P, Terry K, et al. Long-term health-related quality of life and symptom severity following hysterectomy, myomectomy, or uterine artery embolization for the treatment of symptomatic uterine fibroids. American journal of obstetrics and gynecology. 2023;229(3):275. e1-. e17. Roussis NP, Waltrous L, Kerr A, Robertazzi R, Cabbad MF. Sexual response in the patient after hysterectomy: total abdominal versus supracervical versus vaginal procedure. American journal of obstetrics and gynecology. 2004;190(5):1427-8. Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu Y-S, et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstetrics & Gynecology. 2013;122(2 PART 1):233 − 41. Lieng M, Qvigstad E, Istre O, Langebrekke A, Ballard K. Long-term outcomes following laparoscopic supracervical hysterectomy. Obstetrical & Gynecological Survey. 2009;64(3):158-9. Zhang K, Jiang J-H, Hu J-L, Liu Y-L, Zhang X-H, Wang Y-M, et al. Large pelvic mass arising from the cervical stump: a case report. World Journal of Clinical Cases. 2020;8(1):149. Hannoun-Lévi J-M, Peiffert D, Hoffstetter S, Luporsi E, Bey P, Pernot M. Carcinoma of the cervical stump: retrospective analysis of 77 cases. Radiotherapy and oncology. 1997;43(2):147 − 53. Liu Z, Sun B, Feng M, Liu Y. Leiomyosarcoma of cervical stump following subtotal hysterectomy: a case report and review of literature. Eur J Gynaecol Oncol. 2016;37(1):2016. Kho RM, Magrina JF. Removal of the retained cervical stump after supracervical hysterectomy. Best Practice & Research Clinical Obstetrics & Gynaecology. 2011;25(2):153-6. McHale MP, Smith AJB, Fader AN, Wethington SL. Outcomes of women undergoing excision of the retained Cervix after Supracervical Hysterectomy. Obstetrics & Gynecology. 2021;137(5):831-6. Sloth SB, Schroll JB, Settnes A, Gimbel H, Rudnicki M, Topsoee MF, et al. Systematic review of the limited evidence for different surgical techniques at benign hysterectomy: A clinical guideline initiated by the Danish Health Authority. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2017;216:169 − 77. Bland PB. Gynecology: Medical and Surgical1925. Wharton LR. Gynecology: With a section on female urology. (No Title). 1947. Roenneburg ML. Cervical Stump Extirpation. Hysterectomy: A Comprehensive Surgical Approach. 2018:1101-5. Mattingly RF, Te Linde RW, Thompson JD. Te Linde's operative gynecology: Lippincott; 1985. Obstetricians ACo, Gynecologists. ACOG Committee Opinion No. 388 November 2007: supracervical hysterectomy. Obstetrics and gynecology. 2007;110(5):1215-7. Okaro EO, Jones KD, Sutton C. Long term outcome following laparoscopic supracervical hysterectomy. British Journal of Obstetrics and Gynaecology. 2001;108(10):1017-20. Hilger WS, Pizarro AR, Magrina JF. Removal of the retained cervical stump. American journal of obstetrics and gynecology. 2005;193(6):2117-21. Welch JS, Counseller VS, Malkasian Jr GD. The vaginal removal of the cervical stump. Surgical Clinics of North America. 1959;39(4):1073-84. PRATT JH, JEFFERIES JA. The retained cervical stump: a 25-year experience. Obstetrics & Gynecology. 1976;48(6):711-5. Neis F, Reisenauer C, Kraemer B, Wagner P, Brucker S. Retrospective analysis of secondary resection of the cervical stump after subtotal hysterectomy: why and when? Archives of Gynecology and Obstetrics. 2021;304:1519-26. Yoo E-H, Lee PI, Huh C-Y, Kim D-H, Lee B-S, Lee J-K, et al. Predictors of leiomyoma recurrence after laparoscopic myomectomy. Journal of minimally invasive gynecology. 2007;14(6):690-7. Nezhat FR, Roemisch M, Nezhat CH, Seidman DS, Nezhat CR. Recurrence rate after laparoscopic myomectomy. The Journal of the American Association of Gynecologic Laparoscopists. 1998;5(3):237 − 40. Fedele L, Parazzini F, Luchini L, Mezzopane R, Tozzi L, Villa L. Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study. Human Reproduction. 1995;10(7):1795-6. Rossetti A, Sizzi O, Soranna L, Cucinelli F, Mancuso S, Lanzone A. Long-term results of laparoscopic myomectomy: recurrence rate in comparison with abdominal myomectomy. Human Reproduction. 2001;16(4):770-4. Singh SS, Belland L. Contemporary management of uterine fibroids: focus on emerging medical treatments. Current medical research and opinion. 2015;31(1):1–12. Kotani Y, Tobiume T, Fujishima R, Shigeta M, Takaya H, Nakai H, et al. Recurrence of uterine myoma after myomectomy: Open myomectomy versus laparoscopic myomectomy. Journal of Obstetrics and Gynaecology Research. 2018;44(2):298–302. Reed SD, Newton KM, Thompson LB, McCrummen BA, Warolin AK. The incidence of repeat uterine surgery following myomectomy. Journal of women's health. 2006;15(9):1046-52. Mathew SD, Abraham B. Cervical Stump Fibroidpost Supra-cervical Hysterectomy. International Journal of Integrated Health Sciences. 2018;6(2):97 − 9. KRISHNAMOORTHY JK. Recurrent huge leiomyoma from the cervical stump-a rare case report. University Journal of Surgery and Surgical Specialities. 2018;4(4). Sturdy D. Leiomyosarcoma of cervical stump following subtotal hysterectomy. Journal of British Surgery. 1959;46(198):369 − 70. Sheth S. Vaginal excision of cervical stump. Journal of Obstetrics and Gynaecology. 2000;20(5):523-4. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Sep, 2024 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Revision requested 29 Jul, 2024 Reviewers agreed at journal 29 Jul, 2024 Reviews received at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviews received at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviews received at journal 28 Jul, 2024 Reviews received at journal 28 Jul, 2024 Reviews received at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers invited by journal 28 Jul, 2024 Submission checks completed at journal 25 Jul, 2024 Editor invited by journal 24 Jul, 2024 Editor assigned by journal 28 Jun, 2024 First submitted to journal 12 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4258070","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":333055805,"identity":"2edd17db-bc7b-4f93-a981-8de1482813e4","order_by":0,"name":"Ahmed Shoukry","email":"data:image/png;base64,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","orcid":"","institution":"Alexandria University","correspondingAuthor":true,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Shoukry","suffix":""},{"id":333055806,"identity":"a3497066-6d75-4d47-8621-95a76a08d392","order_by":1,"name":"Mahmoud Yousri","email":"","orcid":"","institution":"Alexandria University","correspondingAuthor":false,"prefix":"","firstName":"Mahmoud","middleName":"","lastName":"Yousri","suffix":""}],"badges":[],"createdAt":"2024-04-12 13:31:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4258070/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4258070/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-024-03326-2","type":"published","date":"2024-09-10T15:56:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63313328,"identity":"c8c69da9-2eb2-40e9-b66d-79d250c21dc4","added_by":"auto","created_at":"2024-08-26 20:53:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1257194,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal T2W image showing (\u003cstrong\u003eA\u003c/strong\u003e) the remaining cervical stump with its endometrial lining and (\u003cstrong\u003eB\u003c/strong\u003e) heterogeneous lobulated mainly hypo-intense solid lesion showing areas of cystic changes consistent with cervical leiomyomata.\u003c/p\u003e","description":"","filename":"floatimage133.png","url":"https://assets-eu.researchsquare.com/files/rs-4258070/v1/378fbaec4e19065c54b522c8.png"},{"id":63313329,"identity":"18068721-bf54-4bc1-a8c4-bb206a985002","added_by":"auto","created_at":"2024-08-26 20:53:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2056109,"visible":true,"origin":"","legend":"\u003cp\u003eShowing the surgical specimen, the largest leiomyomata were excised first to facilitate resection of the cervical stump.\u003c/p\u003e","description":"","filename":"floatimage227.png","url":"https://assets-eu.researchsquare.com/files/rs-4258070/v1/513f2c455909782278fe5660.png"},{"id":64619117,"identity":"b3c90fd1-d9cc-4fda-aed7-e4debbd5b918","added_by":"auto","created_at":"2024-09-16 16:11:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4152783,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4258070/v1/0828ff19-dc83-442c-82d5-b7aeafc418f4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cervical stump leiomyomata after supracervical hysterectomy; a case report with review of literature","fulltext":[{"header":"Background","content":"\u003cp\u003eHysterectomy is the most frequently used surgical procedure for women with symptomatic uterine fibroids.(1, 2)\u003c/p\u003e \u003cp\u003ePreservation of the cervix uteri during a hysterectomy is a highly debated issue. Some of the potential benefits of supracervical hysterectomy (SCH) that proponents often mention are reduced blood loss, a shorter hospital stay, fewer intraoperative risks, less urinary manifestations, and better pelvic support(3\u0026ndash;5). Although postoperative sexual function is presumed to be more satisfactory after SCH (6, 7), it was not found to be superior to a total hysterectomy (TH).(8\u0026ndash;10) On the contrary, some problems have been often described with SCH as cyclic bleeding, pelvic pain, and a higher incidence of cervical disease(11).\u003c/p\u003e \u003cp\u003eCervical stump leiomyomas, cysts, cervical prolapse, endometriosis, precancerous lesions, and stump carcinoma are among the morbidities that may develop in the retained cervical stump. The literature indicates that the prevalence of cervical stump carcinoma is about 2\u0026ndash;9% of all cervical carcinomas (12, 13). Additionally, leiomyosarcoma is an extraordinary rare lesion that may arise in the cervical stump following a SCH.(14)\u003c/p\u003e \u003cp\u003eAmong the commonest clinical indications for surgical excision of the cervical stump following supracervical hysterectomy are pelvic masses and vaginal bleeding(15). It has been cited that fibroids are the most common \u0026ndash; in approximately 35% \u0026ndash; pathology found in the excised cervical stump (16). We report a case of a large stump fibroid after a subtotal abdominal hysterectomy.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eA 41-year-old nulliparous woman, presented with pelvic pain and offensive vaginal discharge with occasional vaginal spotting. Her past history is significant for four times of abdominal myomectomies for recurrent fibroid uterus, last one was 10 years ago. Two years after that, she underwent a subtotal abdominal hysterectomy with preservation of the ovaries also due to recurrent leiomyomas after myomectomy, operative specimen examination revealed a 2500-gm uterus with multiple interstitial and subserous leiomyomata ranging from 2\u0026ndash;9.5 cm, histopathological examination confirmed the diagnosis of typical leiomyoma pathological features with no atypical or mitotic figures. All the surgeries were performed via vertical midline incisions. Her medical history is irrelevant expect for mild bronchial asthma controlled with periodic beta-agonist inhalers.\u003c/p\u003e \u003cp\u003eOn examination, her abdomen is lax, non-tender, with no palpable masses. Speculum examination revealed normal looking cervix with a well-estrogenized vagina. By bimanual examination, a firm, non-tender, pelvic mass was appreciated that has a limited mobility conjugated with movement of the cervix.\u003c/p\u003e \u003cp\u003eA transvaginal ultrasound revealed a heterogeneous, irregular pelvic mass, giving the picture of degenerated fibroids measuring 10.2x7.6x6.5 cm encroaching on the right adnexa, with normal appearance of the left ovary. The mass looks suspicious for malignancy so a confirmatory magnetic resonance imaging (MRI) with IV gadolinium contrast was performed - demonstrated in figure (1) - showed heterogeneous T2 lobulated mixed solid and cystic lesion showing mainly hypo-intense signal in T2 and T1 weighted image epicentered upon the cervical stump and engulfing the right adnexa. Patient was counselled for exploratory laparotomy and resection of the mass.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (1)\u003c/strong\u003e \u003cp\u003eSagittal T2W image showing (\u003cb\u003eA\u003c/b\u003e) the remaining cervical stump with its endometrial lining and (\u003cb\u003eB\u003c/b\u003e) heterogeneous lobulated mainly hypo-intense solid lesion showing areas of cystic changes consistent with cervical leiomyomata.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSurgical details\u003c/strong\u003e \u003cp\u003eAn extended lower midline incision was opted for to optimize exposure as well as to allow exploration of the entire abdominal cavity. Upon entry of the abdomen, a large pelvi-abdominal mass was noticed, which was entirely covered by densely adherent bowel posteriorly, and an exceptionally high bladder anteriorly. A lateral approach, opening and utilizing the retroperitoneal avascular pelvic spaces, was used to properly identify the borders of the mass and secure important adjacent structures, namely the ureters, iliac vessels, and recto-sigmoid. Development of the para-vesical and para-rectal spaces bilaterally, facilitated identification of the ureters and iliac vessels, followed by ureterolysis and lateralization of both ureters. Dissection of the densely adherent recto-sigmoid off the back of the mass with development of the rectovaginal space and identification of uterosacral ligaments. Decision was made to excise the fibroids off the cervical stump to optimize exposure of the cervical stump and allow for safe trachelectomy procedure Excision of the cervical stump using a retrograde approach after anterior colpotomy, allowing for preservation of maximal vaginal length. Suturing of the vaginal cuff in a single layer of continues suture fashion. Figures\u0026nbsp;(2) illustrates the surgical specimen showing the excised cervix harboring multiple leiomyomata.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (2)\u003c/strong\u003e \u003cp\u003eshowing the surgical specimen, the largest leiomyomata were excised first to facilitate resection of the cervical stump.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s postoperative course was uneventful and she was discharged after 5 days. Pathological examination of the specimen confirmed the diagnosis of multiple leiomyomata of the cervical stump with marked hyaline, mucoid, and cystic degeneration.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOne of the simplest and most successful treatments for fibroids, adenomyosis, and functional uterine bleeding is hysterectomy. Total hysterectomy and subtotal or supracervical hysterectomy are two categories of hysterectomy based on the extent of operation (17).\u003c/p\u003e \u003cp\u003eBland (1925) defined the subtotal or supracervical hysterectomy as \"one of the safest major operations performed within the abdomen cavity.\" (18). During this era with no access to antibiotics and blood transfusion, SCH was much preferred to TH as it was reported that TH associated with a significantly higher complication rate including mortality (19, 20). Nowadays, SCH contributes to only a very small percentage of all hysterectomies (20, 21).\u003c/p\u003e \u003cp\u003eConservation of the cervix with hysterectomy is associated with increased risk of cervical diseases such as polyps, fibroids, endometriosis, cysts, premalignant, and cervical malignancies which may develop many years after hysterectomy. It was reported that after SCH, 7\u0026ndash;20% of women may suffer from problematic periodic bleeding that could necessitate cervical stump resection (12). According to data from the ACOG, 23 percent of women needed to be reoperated at least 14 months after their first surgery in order to have their cervical stump removed, and 1.5% of patients needed a second procedure to remove the cervical stump less than three months after their initial subtotal hysterectomy (22). In the study of Okaro et al, they reported that women who underwent supracervical hysterectomy have approximately 23% risk of trachelectomy (23). The most commonly cited indication for cervical stump resection in the published literature is cervical prolapse followed by pelvic mass/vaginal bleeding (24\u0026ndash;27)\u003c/p\u003e \u003cp\u003eFibroids have always been described as the \u0026ldquo;recurring disease\u0026rdquo;. After myomectomy there are variable reported rates of recurrence include 12\u0026ndash;15%, 31\u0026ndash;43%, 51\u0026ndash;62%, and 84% at 1, 3, 5, and 8 years respectively (28\u0026ndash;33) and approximately 10\u0026ndash;21% of women will undergo a hysterectomy within 5\u0026ndash;10 years of myomectomy (32, 34). Recurrence of fibroids has been also described after hysterectomy (2, 35, 36), also the case presented here demonstrates that cervical stump may give rise to leiomyomatous growth. In a retrospective analysis of 137 patients underwent cervical stump resection after SCH, Neis F., et al reported that 3.7% of these patients have fibroids in their cervical stumps (27). Similarly, fibroids were found in 2 patients underwent cervical stumpectomy after SCH in a cohort of 309 patients reported by Hilger et al (24).\u003c/p\u003e \u003cp\u003eThere are many explanations for myomas recurrence after hysterectomy such as microscopic or macroscopic remaining fibroid remnants, rapture of leiomyoma capsule leading to seeding, lymphovascular spread, myoma morcellation, and mesothelial mesenchyme metaplasia (2). In cases of fibroid recurrence post SCH, it is mainly attributed to either microscopic cervical fibroid that grow after excision of the uterine corpus, leiomyomatous residuals \u0026ndash; either micro or macroscopic \u0026ndash; in the cervical surgical margin, or rarely due to de novo growth of a cervical fibroid. It is noted that the majority of leiomyomatous recurrence after subtotal hysterectomy occur when ovarian preservation is carried out at time of hysterectomy, as also in our presented case.\u003c/p\u003e \u003cp\u003eCervical stump leiomyomata are usually of a great concern because they often need surgical treatment as myomectomy or trachelectomy which may lead to significant surgical morbidity mainly bladder, ureteric, or bowel injury. Also the possibility of malignant disease is another issue as leiomyosarcoma has been reported in the cervical stump after subtotal hysterectomy (37).\u003c/p\u003e \u003cp\u003eBoth abdominal \u0026ndash; whether laparoscopic or open \u0026ndash; and vaginal routes are described for cervical stump resection, vaginal approach is cited with a lower complication rate (27%) versus 43% in the abdominal approach (24, 38). In a recent series of 137 cases of stump resection, the vaginal route was used in 75% of patients (27). Limitations to the vaginal approach are the existence of a suspected adnexal tumor or cervical malignancy. The requirement for simultaneous pelvic exploration in order to evaluate associated chronic pelvic pain, remove endometriosis, or both, would additionally require a non-vaginal route as laparoscopy (15). Vaginal approach is the preferred route especially in cases of cervical prolapse after SCH.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSupracervical or subtotal hysterectomy could be performed in selected women with appropriate counselling, mainly in cases of multiple leiomyomata and the selected candidate should be told about the potential of recurrent fibroids in the retained cervical stump and its consequences including the need for reoperation for cervical stump resection.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esupracervical hysterectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etotal hysterectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACOG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican College of Obstetrics and Gynecology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the surgical and anesthesia team of Shatby Women University Hospital where the surgery was performed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAS was the main surgeon and wrote the manuscript. MS was the main surgical assistant, read, revised, and approved the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have received no external funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data for the case report are available in this manuscript upon reasonable request. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declared that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA written consent was obtained from the patient for publication of this case report.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eWhiteman MK, Hillis SD, Jamieson DJ, Morrow B, Podgornik MN, Brett KM, et al. 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ACOG Committee Opinion No. 388 November 2007: supracervical hysterectomy. Obstetrics and gynecology. 2007;110(5):1215-7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOkaro EO, Jones KD, Sutton C. Long term outcome following laparoscopic supracervical hysterectomy. British Journal of Obstetrics and Gynaecology. 2001;108(10):1017-20.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHilger WS, Pizarro AR, Magrina JF. Removal of the retained cervical stump. American journal of obstetrics and gynecology. 2005;193(6):2117-21.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWelch JS, Counseller VS, Malkasian Jr GD. The vaginal removal of the cervical stump. Surgical Clinics of North America. 1959;39(4):1073-84.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePRATT JH, JEFFERIES JA. The retained cervical stump: a 25-year experience. 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The Journal of the American Association of Gynecologic Laparoscopists. 1998;5(3):237\u0026thinsp;\u0026minus;\u0026thinsp;40.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFedele L, Parazzini F, Luchini L, Mezzopane R, Tozzi L, Villa L. Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study. Human Reproduction. 1995;10(7):1795-6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRossetti A, Sizzi O, Soranna L, Cucinelli F, Mancuso S, Lanzone A. Long-term results of laparoscopic myomectomy: recurrence rate in comparison with abdominal myomectomy. Human Reproduction. 2001;16(4):770-4.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSingh SS, Belland L. Contemporary management of uterine fibroids: focus on emerging medical treatments. Current medical research and opinion. 2015;31(1):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKotani Y, Tobiume T, Fujishima R, Shigeta M, Takaya H, Nakai H, et al. Recurrence of uterine myoma after myomectomy: Open myomectomy versus laparoscopic myomectomy. Journal of Obstetrics and Gynaecology Research. 2018;44(2):298\u0026ndash;302.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eReed SD, Newton KM, Thompson LB, McCrummen BA, Warolin AK. The incidence of repeat uterine surgery following myomectomy. Journal of women\u0026apos;s health. 2006;15(9):1046-52.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMathew SD, Abraham B. Cervical Stump Fibroidpost Supra-cervical Hysterectomy. International Journal of Integrated Health Sciences. 2018;6(2):97\u0026thinsp;\u0026minus;\u0026thinsp;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKRISHNAMOORTHY JK. Recurrent huge leiomyoma from the cervical stump-a rare case report. University Journal of Surgery and Surgical Specialities. 2018;4(4).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSturdy D. Leiomyosarcoma of cervical stump following subtotal hysterectomy. Journal of British Surgery. 1959;46(198):369\u0026thinsp;\u0026minus;\u0026thinsp;70.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSheth S. Vaginal excision of cervical stump. Journal of Obstetrics and Gynaecology. 2000;20(5):523-4.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Subtotal, Supracervical, Hysterectomy, Fibroids","lastPublishedDoi":"10.21203/rs.3.rs-4258070/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4258070/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite being highly debated issue, subtotal or supracervical hysterectomy is still considered a safe and effective treatment for women with multiple fibroid uterus. Many lesions could arise on top of the preserved cervical stump such as recurrence of fibroids, cervical polyps, endometriosis, or malignancies which may necessitate reoperation and resection of the cervical stump or trachelectomy. Trachelectomy is known to be a difficult surgical procedure that may be associated with significant intra and post-operative morbidity.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe presented here a case with a pelvic mass related to the cervical stump presented 8 years after subtotal hysterectomy. She complained of pelvic pain and vaginal discharge and spotting. Transvaginal sonography and magnetic resonance imaging were performed and a heterogeneous pelvic mass was revealed. Surgical exploration and resection of the mass with cervical stump excision was performed. Histopathology conformed the diagnosis of cervical stump multiple leiomyomata.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSupracervical or subtotal hysterectomy could be performed in selected women with appropriate counselling, mainly in cases of multiple leiomyomata and the selected candidate should be told about the potential of recurrent fibroids in the retained cervical stump and its consequences including the need for reoperation for cervical stump resection.\u003c/p\u003e","manuscriptTitle":"Cervical stump leiomyomata after supracervical hysterectomy; a case report with review of literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-26 20:53:07","doi":"10.21203/rs.3.rs-4258070/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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