CANSAGE Presentation: Surgical Approach to Parasitic Fibroids скачать в хорошем качестве

CANSAGE Presentation: Surgical Approach to Parasitic Fibroids

This video reviews the laparoscopic management of a parasitic fibroid located in the space of Retzius, an uncommon extra-uterine site for fibroid growth. Parasitic fibroids account for less than 1% of all fibroids and can arise either by auto-amputation of a pedunculated fibroid or by tissue dissemination at the time of prior surgery. The patient was a 47-year-old nulligravida with persistent lower urinary tract symptoms and pelvic discomfort despite medical therapy. She had undergone a minimally invasive hysterectomy for fibroids eight years earlier. Pelvic sonography showed a 4 cm smooth mass near the proximal urethra. MRI confirmed a well-circumscribed lesion anterior and inferior to the bladder, consistent with a parasitic fibroid. After laparoscopic entry, inspection revealed a smooth, firm, rounded mass anterior to the vaginal vault. A Foley catheter balloon was visible to the right of the mass, and a ring forceps placed in the vaginal vault helped define its location. Because of the close relationship between the mass and the bladder, methylene blue was instilled into the bladder. The mass disappeared from view trans-peritoneally during instillation, confirming the bladder’s anterior position, as suggested by MRI. Cystoscopy demonstrated extrinsic indentation of the bladder but no mucosal involvement, and both ureteric orifices were normal. To access the lesion, the space of Retzius was opened by incising between the medial umbilical ligaments with a CO₂ laser, a corridor that avoids the inferior epigastric vessels. The space is bounded by the parietal peritoneum superiorly, symphysis pubis anteriorly, arcus tendineus fascia pelvis laterally, bladder posteriorly, and the proximal urethra and bladder neck inferiorly. Perivesical fat was dissected while the bladder was insufflated with CO₂ to identify its dome. Dissection continued to the pubic rami, exposing the iliopectineal ligaments bilaterally, until the mass was visualised anterior to the bladder. The fibroid was carefully freed using a combination of CO₂ laser and bipolar cautery. Haemostasis was secured, and cystosufflation was repeated to outline the bladder and confirm its integrity. No bladder injury was detected. The opening to the space of Retzius was then closed with a 2-0 Maxon monofilament suture tied with an extracorporeal Roeder knot and advanced intracorporeally with a knot pusher. The patient was discharged home the same day after a successful voiding trial and reported marked improvement in urinary symptoms at follow-up.