Complete excision of pelvic parasitic fibroid using vnotes in morbidly obese patient, case report and review of literature

A 49-year-old female presented complaining of heavy menstrual bleeding for three days, occurring at regular intervals and a feeling of a bulge through the vagina. She is known to have hypertension, cardiomyopathy and pulmonary hypertension. On examination, she exhibited morbid central obesity (BMI of 50.39) and was found to have stage four pelvic organ prolapse of all compartments, along with a mass filling the posterior pouch of Douglas. Ultrasound and MRI done Picture 1 , Picture 2 , Picture 3 imaging revealed diffuse adenomyosis, a right degenerated subserosal fibroid measuring 65 × 46 x 53 mm, and a normal endometrial sample and a Pap smear was performed. Due to the patient's comorbidities, a pessary ring (size 5) was inserted as a temporary measure to facilitate pre-anaesthesia clearance. However, the pessary fell out, and the patient was uncomfortable with the placement of another one. Picture 1 T2 coronal view of the pelvic MRI shows an adenomyotic uterus with a thickened junctional zone measuring 1.3 cm. A right pelvic lesion displays heterogeneous low T2 signal intensity with a marked peripheral low T2 signal intensity rim. This lesion is inseparable from the right ovary and the uterine fundus, likely representing red degeneration of a subserosal fibroid. Picture 2 vNOTES view of the mass post-hysterectomy shows a mass measuring 7.5 cm, with multiple filmy adhesions and blood supply from surrounding tissues. Picture 3 Excised mass, uterus and bilateral tubes and ovaries. T2 coronal view of the pelvic MRI shows an adenomyotic uterus with a thickened junctional zone measuring 1.3 cm. A right pelvic lesion displays heterogeneous low T2 signal intensity with a marked peripheral low T2 signal intensity rim. This lesion is inseparable from the right ovary and the uterine fundus, likely representing red degeneration of a subserosal fibroid. vNOTES view of the mass post-hysterectomy shows a mass measuring 7.5 cm, with multiple filmy adhesions and blood supply from surrounding tissues. Excised mass, uterus and bilateral tubes and ovaries. Given the patient's morbid and central obesity, a decision was made to proceed with a classical vaginal hysterectomy, with the employment of vaginal natural orifice transluminal endoscopic surgery (vNOTES) technique as a supplementary approach if needed. During the procedure, a classical vaginal hysterectomy was performed, during which the mass could not be seen or felt initially. For that, the vNOTES technique was utilized to explore and excise the mass. A 9.5 cm GelPOINT V-path was used, with insufflation maintained at a maximum of 12 mmHg and the patient in a slight Trendelenburg position. The mass was fully visualised, measuring 7.5 × 5.5 cm, and was located on the right pelvic sidewall. It was not attached to the uterus. The mass was semi-solid, with various attachments to surrounding structures, and received its blood supply from the rectosigmoid, pelvic sidewall, fallopian tubes, and bladder. Careful dissection with a vessel-sealing device was performed, leading to complete excision of the mass. Prolapse correction was achieved through sacrospinous vault suspension and repair of the cystocele and rectocele. Surgery completed without intraoperative complications and estimated blood loss of 300 ml. Haemoglobin levels remained stable pre- and postoperatively, measuring 12.8 g/dL and 12.2 g/dL, respectively. Histopathology revealed a 118-gram leiomyoma measuring 7.5 × 5.5 × 3 cm, showing extensive ischemic-type necrosis consistent with leiomyoma, with no evidence of malignancy. The patient was discharged on the first day post-surgery and reported significant improvement at a follow-up two months later, with a satisfaction score of 10 out of 10.

Reem Alenazi: Writing – original draft, Validation, Conceptualization. Jawaher Alsahabi: Writing – review & editing, Writing – original draft, Validation, Supervision, Resources, Project administration, Investigation, Data curation, Conceptualization. Taif alhamad: Writing – original draft, Resources, Data curation, Conceptualization. dawood ashraf: Writing – original draft, Validation, Supervision, Data curation, Conceptualization.

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

To our knowledge, this is the first documented case of a spontaneous parasitic fibroid treated using VNOTES (vaginal natural orifice transluminal endoscopic surgery). This unique case not only emphasizes the potential effectiveness of VNOTES for addressing rare fibroid pathologies but also suggests its suitability for use in obese patients, who may face additional challenges during traditional surgical interventions. parasitic

There are very few cases in the literature of spontaneous or primary parasitic fibroids in patients without a prior history of myomectomy, particularly those involving morcellation ( Table 1 ). Our case is the 10th reported instance of a spontaneous parasitic fibroid that developed without any prior morcellation or pelvic surgery. A parasitic leiomyoma is classically defined as a pedunculated subserosal fibroid that undergoes torsion, detaches from the uterus, and continues to grow via neovascularisation from adjacent tissues [1] , [2] , [3] . This may explain the extensive necrosis observed in the histology of the excised fibroid in our case. Table 1 "Summary of reported cases of primary or spontaneous parasitic fibroids in the literature.". Author, Year Age Presentation Diagnosis Surgery Intraoperative findings description Size of the fibroid Mana Iida, 2016 [13] 20 Abdominal pain TV, Ultrasound Laparoscopy The tumour was supplied from the omentum, which was tightly adherent to the tumour. 5 cm Rubina Mushtaq,2017 [14] 28 painless mass and abdominal distension Ct Laparotomy it was found to be attached by a small pedicle with the uterus with large blood vessels between the parasitic fibroid and omentum 10.3 × 17.6 × 19.4 cm A. M. Salih, 2017 [15] 46 upper abdominal heaviness, swelling, nausea, palpitations, and shortness of breath ultrasound and CT Laparotomy The mass was located in the epigastric region on the greater omentum. 12 × 10 cm Nkencho Osegi,2019 [2] 58 progressive abdominal swelling of three-year duration Abdominopelvic ultrasound and CT Laparotomy It derived its blood supply from the greater omentum to which it was attached with huge visible arteries and veins. 22.4 × 16 x 25 cm Georgia Micha, 2022 [3] 33 severe right iliac fossa (RIF) pain. TVS Laparotomy The fibroid’s major blood supply was provided by A large vessel originated from the peritoneum, and the fibroid was held in place close to the uterus due to the adhesions. 6.3 × 4.6 cm Archana Barik,2022 [16] 75 pain and heaviness in the lower abdomen for four months. Abdominopelvic ultrasonography And MRI Laparotomy The mass was completely free from the uterus and was found to have adhered to the right infundibulopelvic ligament. It was also attached to the sigmoid colon and lateral pelvic wall with flimsy adhesions. 10 × 10 x7.5 cm Hyo Kyozuka, 2022 [17] 40 heavy menstrual bleeding MRI Laparoscopy Thumb-sized tumor on the left side of the peritoneum thumb-sized Naoki Shibata, 2024 [1] 51 Dysmenorrhea MRI Robotic A pedunculated sub serosal myoma was firmly attached to the right‑side retroperitoneum of the vesicouterine pouch 3 cm Shunsuke Yasumi, 2024 [18] 45 Iron deficiency anemia TV ultrasound Laparoscopy A retroperitoneal solid tumor on the left side of the pouch of Douglas 1.8 cm "Summary of reported cases of primary or spontaneous parasitic fibroids in the literature.". Table 1 presents a review of reported cases of primary parasitic fibroids in the literature to date. The reported cases typically present with a range of symptoms, most commonly pain, heavy bleeding, or anaemia. In our case, the primary symptom was abnormal uterine bleeding, which was accompanied by symptoms of advanced prolapse. All patients underwent imaging prior to surgery; however, nearly all reports indicate that a definitive diagnosis of a parasitic fibroid was made intraoperatively due to the mass's close proximity to the uterus [1] , [3] , [13] , [14] , [15] , [16] , [17] , [18] . The exceptions were cases where the mass was located away from the pelvis, where a diagnosis was made prior to surgery [15] . In the current published case reports of spontaneous parasitic fibroids, surgical intervention was performed primarily through laparotomy in most instances, with masses typically measuring 10 cm or larger. The second most common approach was laparoscopy, which was used in three cases, while one case involved robotic surgery. None of the published cases employed the vNOTES approach for surgery; therefore, to our knowledge, our case is the first in the literature documenting the excision of a parasitic fibroid using this method. As obesity rates continue to rise globally, it is important to note that obesity is linked to both intraoperative and postoperative complications [6] , [7] . This condition can make surgical procedures more challenging due to factors such as a thick abdominal wall, substantial intra-abdominal fat, bulky vaginal tissue, and poor tolerance for the Trendelenburg position [6] . Given these challenges, vaginal natural orifice transluminal endoscopic surgery (vNOTES) presents a viable option for obese patients. With its proven safety and effectiveness, vNOTES can be routinely utilised for various gynaecological procedures [5] .

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Uterine myomas, commonly known as fibroids, are benign tumours frequently found in the pelvis [1] . In contrast, parasitic myomas are rare and can detach from the uterus, form their own blood supply, and attach to other structures [1] . These fibroids may develop following surgical procedures, particularly after morcellation, or arise spontaneously due to mechanisms such as twisting and detachment, though the exact causes remain unclear [2] , [3] . It is suggested that parasitic myomas develop through a process that begins with initial adhesion, followed by the establishment of collateral blood flow, degeneration of the stalk, and eventual detachment from the uterus (1,2). One treatment option is surgical intervention. However, it is important to consider that obese individuals often experience hormonal imbalances, which increase their risk for conditions such as abnormal uterine bleeding and the need for surgical intervention [4] , [5] , [6] . Furthermore, obesity is strongly linked to intraoperative and postoperative complications [7] . For this reason, minimally invasive techniques are vital for reducing morbidity in obese individuals [5] . Data on intraoperative conversion rates and perioperative and postoperative complications suggest that vNOTES (vaginal natural orifice transluminal endoscopic surgery) is feasible for obese patients [5] . Given the safety and effectiveness of vNOTES, it can be routinely used in various gynecologic procedures [5] , [8] , [9] . The transvaginal approach allows surgeons to avoid intra-abdominal adhesions by accessing the surgical site directly [4] , [10] , [11] . Jan Baekelandt described the use of vNOTES for treating different types of myomas [12] , noting that there were no complications and the outcomes were favourable. However, to our knowledge, there are no existing reports in the literature regarding the use of vNOTES for parasitic fibroids. This case report presents two novel clinical features. First, it highlights the presence of a spontaneous parasitic fibroid, which detaches from the uterus and relies on an alternative source for its blood supply [10] , [13] . Second, it demonstrates that parasitic myomas in the retroperitoneum can be safely resected via vNOTES.

We confirm that our manuscript has received IRB approval, and we do not have anything to disclose or any conflicts of interest.