Ultrasound features of highly vascularized uterine myomas (uterine smooth muscle tumors) and correlation with histopathology.

OBJECTIVE: To correlate the ultrasound appearance of highly vascularized uterine myomas with their histopathological diagnosis. METHODS: This was a prospective observational study of patients with a preoperative ultrasound diagnosis of a highly vascularized uterine myoma (color score of 3 or 4, according to the Morphological Uterus Sonographic Assessment (MUSA) criteria), characterized by circumferential and intralesional vascular pattern, who underwent myomectomy or hysterectomy. For each patient, ultrasound characteristics were recorded at baseline, including the number of lesions, the size, echogenicity and border regularity of the lesion, presence of cystic areas and shadowing within the myoma, and visualization of the endometrium. Ultrasound features were correlated with the definitive histological diagnosis. Ultrasound features were then compared between malignant and benign lesions. RESULTS: We included 70 patients with highly vascularized uterine myomas on power/color Doppler. Their mean age was 46.5 ± 11.4 years and 13 (18.6%) were postmenopausal. At histological examination, 65 (92.9%) uterine myomas were benign lesions, comprising 32 typical leiomyomas, 29 leiomyoma variants and four adenomyomas. The remaining five (7.1%) uterine myomas were malignant masses, comprising two uterine sarcomas, one leiomyosarcoma, one neuroendocrine tumor and one uterine smooth muscle tumor of uncertain malignant potential (STUMP). The mean age of patients with a malignant lesion was significantly higher than the age of those with a benign lesion (64.8 ± 16.0 vs 42.4 ± 5.1; P < 0.001). Four out of five patients with a malignant lesion were over 45 years old. Ultrasound demonstrated cystic areas within the lesion in 10/32 (31.3%) typical leiomyomas, 16/29 (55.2%) leiomyoma variants, all four adenomyomas and in the cases of STUMP and leiomyosarcoma. Lesion borders were regular in 64/65 (98.5%) benign lesions and 2/5 (40%) malignant lesions (P < 0.05). No significant differences were observed between benign and malignant lesions with respect to echogenicity, presence of shadowing and size. The endometrium was visible in 55/65 women with benign lesions and in 2/5 with malignant lesions (P = 0.03). CONCLUSIONS: Our results showed that ultrasound features of uterine myomas, such as circumferential and intralesional vascularity, cystic areas and lesion borders, are important parameters for differential diagnosis, especially when combined with the patient's age. Such features could be useful to differentiate typical myomas from benign variants and malignant lesions in a preoperative setting and to select patients that may benefit from conservative management rather than surgery. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Using rADioMIcs and machine learning with ultrasonography for the differential diagnosis of myometRiAL tumors (the ADMIRAL pilot study). Radiomics and differential diagnosis of myometrial tumors.

OBJECTIVE: To develop and evaluate the performance of a radiomics and machine learning model applied to ultrasound (US) images in predicting the risk of malignancy of a uterine mesenchymal lesion. METHODS: Single-center retrospective evaluation of consecutive patients who underwent surgery for a malignant uterine mesenchymal lesion (sarcoma) and a control group of patients operated on for a benign uterine mesenchymal lesion (myoma). Radiomics was applied to US preoperative images according to the International Biomarker Standardization Initiative guidelines to create, validate and test a classification model for the differential diagnosis of myometrial tumors. The TRACE4 radiomic platform was used thus obtaining a full-automatic radiomic workflow. Definitive histology was considered as gold standard. Accuracy, sensitivity, specificity, AUC and standard deviation of the created classification model were defined. RESULTS: A total of 70 women with uterine mesenchymal lesions were recruited (20 with histological diagnosis of sarcoma and 50 myomas). Three hundred and nineteen radiomics IBSI-compliant features were extracted and 308 radiomics features were found stable. Different machine learning classifiers were created and the best classification system showed Accuracy 0.85 ± 0.01, Sensitivity 0.80 ± 0.01, Specificity 0.87 ± 0.01, AUC 0.86 ± 0.03. CONCLUSIONS: Radiomics applied to US images shows a great potential in differential diagnosis of mesenchymal tumors, thus representing an interesting decision support tool for the gynecologist oncologist in an area often characterized by uncertainty.

Uterine Myomas: Focused Ultrasound Surgery.

Uterine fibroids are the most common neoplasm in women. These lesions may be associated with impaired fertility and adverse obstetric outcomes. Medical treatment, myomectomy, hysterectomy and uterine artery embolization have been employed for the management of uterine fibroids. Focused ultrasound surgery (FUS) is a relatively recent technique that relies on mechanical and thermal energy of ultrasound for the ablation of a target tissue under an imaging guidance, that can be either ultrasound (US-guided FUS, USgFUS) or magnetic resonance (MR-guided FUS, MRgFUS). Pre- and peri-menopausal women are potential candidates for treatment; however, individual criteria need to be evaluated in order to establish the eligibility for the procedure. FUS procedure can be performed in an outpatient setting; it is a safe and effective treatment that has demonstrated to reduce symptoms associated with uterine fibroids. The adverse event rate is 8.7% and only 0.2% of patients experiences major complications. Pregnancy is possible after the treatment, and no damage to the endometrium has been observed following FUS procedure.

Uterine Myomas: Endovascular Treatment.

Uterine fibroids embolization is a safe and effective organ sparing treatment for fibroid-related symptoms based on a broad range of published evidence including randomized-controlled trials. Indication to treatment is usually the presence of symptomatic uterine fibroids. In this review, a systematic search of journal articles relevant to the treatment of symptomatic uterine fibroids was conducted, with a special focus on the indication to treatment, technique, procedural outcomes and pain control. All clinical trials published in English language, representing original research, and reporting clinical outcomes associated with interventions for the management of symptomatic uterine fibroids were considered.

Uterine Myomas: Extravascular Treatment.

Uterine fibroids are common benign tumors that affect the female reproductive tract. They are responsible for considerable morbidity and deterioration of life quality. The main advantages offered by mini invasive techniques are low grade of invasiveness and short times of hospitalization. The most diffuse technique is uterine artery embolization (UAE). Common concerns with UAE include postprocedural pain, postembolization syndrome, and risk of infection. Image-guided thermal ablation techniques like radiofrequency ablation, percutaneous microwave ablation, and imaging-guided high-intensity focused ultrasound were introduced to overcome the side effects related to UAE and surgery. The aim of this review is to briefly analyze the ablative procedures and their role in the management of symptomatic fibroids, and to describe the safety profile and outcomes of these modalities.

Office hysteroscopic myomectomy without myoma extraction: A multicenter prospective study.

OBJECTIVE: To evaluate the feasibility and safety of leaving the submucous myoma (SM) in the uterine cavity after office hysteroscopic enucleation. STUDY DESIGN: Prospective multicenter study including patients who had a single SM diagnosed by transvaginal ultrasounds with surgical indication. Office hysteroscopic enucleation of the SM was performed using a 5 mm continuous flow office hysteroscope with a 2.9 mm rod lens optical system and a 5 Fr operative channel. After the SM was released preserving the pseudo capsule using cold instruments, it was left into the uterine cavity. The primary endpoint was the proportion of patients without evidence of the myoma at the transvaginal ultrasound performed after 90 days from surgery. RESULTS: Between January 1st, 2018, and March 31st, 2020, a total of 204 patients were enrolled. Most patients were nulliparous and reported abnormal uterine bleeding as the leading symptom. 76.5 % of enucleated myomas had a diameter ranging between 1.5 and 2.5 cm, and 81.4 % of SMs were of G0 or G1. Hysteroscopic procedures had a mean duration of 23.2 ± 10.5 min. The operative time was associated with the SM grade and size. All hysteroscopic procedures were completed. A vasovagal reaction was observed in 3 women (1.5 %), and minimal post-operative bleeding was reported after 7 procedures (3.4 %). None reported pelvic pain or vaginal discharges/bleeding during follow-up. The average patient satisfaction from surgery was 4.59 (5-points Likert scale). The level of patient satisfaction was not associated with the grade and the size of the myoma. In 192 (94.12 %; 98 %CI: 89.03-96.93 %) out of 204 patients, the SM was absent at the transvaginal ultrasound performed at the follow-up end. A higher prevalence of G2 SMs and lower prevalence of G1 SMs were observed among patients with evidence of the myoma after 90 days from the surgery. CONCLUSION: Office hysteroscopic myomectomy with SM enucleation without mass extraction appears safe, well-tolerated, and effective in at least 89 % of patients. G2 SMs may be the factor associated with the procedure's failure.

Transvaginal Ultrasound and Doppler Features of Intraligamental Myomas.

OBJECTIVES: To describe the ultrasound (US) features of intraligamental myomas (IMs) using Morphological Uterus Sonographic Assessment group standardized terminology. METHODS: This was a retrospective monocentric study. A total of 125 consecutive women with a preoperative US diagnosis of a myoma located close to the uterine isthmus (International Federation of Gynecology and Obstetrics stages 5, 6, and 7) from 2016 to 2019 who underwent laparoscopic or laparotomic myomectomy or hysterectomy were included for study analyses. The US data were retrieved from US reports and stored digital images by 2 authors. Ultrasound features of myomas were described according to Morphological Uterus Sonographic Assessment terminology. Clinical data for the study population were retrieved from the patients' records. RESULTS: Nineteen women with a surgical confirmation of an IM were included in the study group; the remaining population constituted the control group (n = 106). Non-uniform echogenicity was detected in 17 of 19 (89%) of IMs compared to 26 of 106 (25%) fibroids in the control group (P < .001). The presence of shadowing was detected in 12 of 19 (63%) IMs compared to 94 of 106 (89%) cases in the control group (P = .004). Intraligamental myomas were more vascularized tumors compared to myomas in the control group (P = .004). Transvaginal US showed high specificity for the diagnosis of an IM (0.93; 95% confidence interval, 0.87-0.96). CONCLUSIONS: On US imaging, IMs appear as vascularized solid tumors with nonuniform echogenicity; cones of shadows were less frequent in IMs than the control group, and this finding can help in the differential diagnosis. Knowledge of their specific US features could help sonographers make an accurate diagnosis, allowing them to plan correct surgery and avoid severe complications.

Antidiastole Value of Three-dimensional Ultrasonography and Power Doppler between Uterine Parenchyma Lumps and Endometrial Cancer: A Retrospective Study.

Sometimes endometrial polyps, submucosal myomas, and endometrial cancer show similar findings under ultrasonography. The aim of this study was to assess the antidiastole value of blood flow parameters using three-dimensional (3D) power Doppler ultrasonography angiography (PDA) between endometrial cancer and uterine parenchyma lumps. The data of the blood flow indices in 3D-PDA including the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) in 40 patients with endometrial cancer and 41 patients with uterine parenchyma lumps (endometrial polyps and submucosal myomas) were retrospectively analysed and compared utilizing Virtual Organ Computer-aided AnaLysis (VOCAL) software. The results showed that all the blood flow parameters (VI, FI, VFI) were significantly higher in women with endometrial cancer than in those with uterine parenchyma lumps (P<0.001). The area under the curve of ROC of VI, FI, and VFI was 0.98, 0.84, and 0.97, respectively. Thus, the best predictor of endometrial carcinoma was VI with a sensitivity of 97.0% and a specificity of 91.0%. The optimal cutoff value of VI was 4.06%. Our data demonstrated that all of the blood flow signal parameters (including VI, FI, and VFI) in 3D power Doppler ultrasonography had significant antidiastole values between endometrial cancer and uterine parenchyma lumps to assist clinicians in properly diagnosing patients.

Disappearance of the blood supply to a giant uterine myoma due to childbirth: A CARE-compliant article.

RATIONALE: Giant uterine myomas may be life-threatening due to pressure effects on the lungs and other contiguous organs. PATIENT CONCERNS: A 32-year-old pregnant Asian woman was admitted to our hospital early in her pregnancy with a pre-pregnancy history of multiple uterine myomas. DIAGNOSIS: She was diagnosed with multiple giant uterine myomas in pregnancy. INTERVENTIONS: No intervention was performed on the woman. OUTCOMES: A reduction in tumor size and disappearance of tumor blood supply were seen on conventional and contrast-enhanced ultrasounds (CEUS) on postpartum day 34. Mass volume gradually decreased and no blood flow signals were seen on CEUS during postpartum follow-up. LESSONS: Childbirth can block the blood supply of giant uterine myomas and reduce mass size. In such cases, childbirth may be considered therapeutic.

Feasibility of quantitative MR-perfusion imaging to monitor treatment response after uterine artery embolization (UAE) in symptomatic uterus fibroids.

INTRODUCTION: In 25% of women, symptomatic uterus myomas are diagnosed with clinical and functional impairment ranging from abdominal and pelvic pain to dys- and hypermenorrhea, dyspareunia, pollakiuria and infertility. Women undergoing a treatment increasingly prefer nowadays minimal invasive, uterus preserving therapies like uterine artery embolization (UAE) over surgical hysterectomy, nowadays. To emphasize the efficacy of UAE as a uterus preserving treatment with targeted therapy of myomas only, analysis of tissue perfusion pre and post embolization is required. The purpose of this study was to assess treatment response in UAE in females with symptomatic uterus myomas by quantitative magnetic resonance perfusion imaging. METHODS: Seven females scheduled for uterus myoma embolization underwent three MRI examinations (pre, post, follow-up) including morphological and dynamic contrast enhanced perfusion imaging at 3 T. To measure tumor volume, regions-of-interest covering the tumor and the uterus were drawn by two readers in consensus. Blood flow, blood volume, and mean transit time were calculated by a pixel-by-pixel deconvolution approach. Kruskal-Wallis/Friedman test was employed to test whether the group medians differ significantly with correction for multiple comparisons using Bonferroni method. RESULTS: Change of volume could be observed in all patients after embolization but was significantly different only between pre/post and follow-up time point. Measured differences in all perfusion parameters were significant between pre-intervention and post-intervention/follow-up in the myomas, no significant differences could be detected for the uterus tissue. CONCLUSIONS: Our results demonstrate devascularization of symptomatic myomas which correlates with cessation of hypermenorrhea in all treated patients without affecting healthy uterus tissue. Supplementing UAE with perfusion imaging to monitor early treatment response is feasible and might provide valuable information for the follow-up of patients and contribute to providing confidence for the patients in treatment success.

Use of pre-operative imaging for symptomatic uterine myomas during pregnancy: a case report and a systematic literature review.

PURPOSE: Uterine fibroids (UFs) occur in 10% of pregnancies and may lead to severe maternal-fetal complications, mainly depending on UFs characteristics and the distance to the uterine cavity (UC). When symptomatic, UFs are managed medically. Nevertheless, in about 2% of cases, surgery becomes necessary. Entry into the UC should be avoided during myomectomy. Consequentially, pre-operative assessment of this risk could be beneficial. Ultrasonography (US) represents the gold standard for UFs assessment; however, scarce evidence has been produced to assess the role of magnetic resonance imaging (MRI). The aim of the present study was to summarize current evidence about the pre-operative use of imaging techniques for UFs during pregnancy. METHODS: A systematic research of the literature was conducted in Scopus, PubMed/MEDLINE, ScienceDirect and the Cochrane Library, including case reports and case series. A case report was also discussed. We collected data regarding patients, imaging assessment, UFs characteristics, surgical information, timing and modality of delivery. RESULTS: According to our search strategy, 66 articles were selected and 210 patients were included. US assessment was reported in 36 (17%) cases. MRI was reported in 10 (4.7%) cases. Only in one case, MRI was used to measure the distance between UFs and UC. CONCLUSION: US allows an adequate pre-operative evaluation of anterior, submucosal or pedunculated symptomatic UFs in pregnancy. However, compared to US, MRI may provide a more accurate evaluation of multiple, large, intramural or posterior UFs and could measure the distance between UFs and UC more accurately.

Robotic single-site myomectomy: A single-center experience of 101 consecutive cases.

BACKGROUND: To evaluate the feasibility and clinical outcomes of robotic single-site myomectomy (RSSM) for uterine myoma. METHODS: Medical records of 101 consecutive women who underwent RSSM were retrospectively reviewed, and patient characteristics and surgical outcomes were evaluated. The surgical outcomes were compared by the phase in learning curve (early phase of <10 cases vs late phase of ≥10 cases) and time flow. RESULTS: A total of 47 (46.5%) women had multiple myomas, and a median two (1-12) myomas were retrieved. The largest myoma was averagely measured as 6.2 ± 1.7 cm, and the mean weight of the total retrieved myomas was 114.0 ± 84.4 g. No patients received a transfusion or had operation-related complications. Cases in the late phase showed shorter port placement time and docking time than those in the early phase. CONCLUSIONS: Our data suggest that robotic single-site surgery is a feasible therapeutic option for uterine myoma.

Uterine fibroid size modifications during pregnancy and puerperium: evidence from the first systematic review of literature.

PURPOSE: The influence of pregnancy on uterine fibroid size still remains an unsolved dilemma. Basing on current knowledge, physicians are not able to inform patients about the likelihood of uterine fibroids to modify their size during pregnancy. Study aim was to summarize available evidence concerning the size modifications of uterine fibroids during each trimester of pregnancy and during puerperium. METHODS: The review was reported following the PRISMA guidelines and registered in PROSPERO (registration number: CRD42017071117). A literature search was conducted in electronic database (PubMed, Embase, Sciencedirect, the Cochrane library and Clinicaltrials.gov) until July 2017. All studies evaluating fibroids' changes during pregnancy and puerperium by ultrasound or magnetic-resonance-imaging were included. Descriptive characteristics of studies and patients were collected. The modifications of uterine fibroid diameter and volume were the outcome measures. RESULTS: Concerning the first trimester of pregnancy, all authors reported a significant growth of uterine fibroids. Contradictory evidence was found about uterine fibroid modifications during the second and third trimesters, mainly supporting a slowdown during mid pregnancy and a subsequent size reduction during late pregnancy. Concerning the overall modifications during pregnancy and puerperium, poor evidence quality suggests that uterine fibroids do not modify their volume/slightly enlarge during pregnancy and subsequently reduce in size during puerperium. CONCLUSIONS: Uterine fibroids seem to be subject to a non-linear trend of modifications during pregnancy and puerperium, which may vary from myoma to myoma. Adequate evidence supports uterine fibroid systematic enlargement during the first trimester of pregnancy, while inconsistent evidence is available about the changes of uterine fibroids during second and third trimesters. In addition, the overall modifications of myomas during pregnancy and puerperium remain unclear.

The Role of Pelvic Ultrasound in Preoperative Evaluation for Laparoscopic Myomectomy.

STUDY OBJECTIVE: To determine the accuracy of pelvic ultrasonography (US) in preoperative evaluation before laparoscopic myomectomy. DESIGN: A prospective cohort study (Canadian Task Force classification II-2). SETTING: A tertiary level referral center of minimally invasive gynecologic surgery, Sant'Orsola University Hospital, Bologna, Italy. PATIENTS: One hundred one of the 125 women undergoing laparoscopic myomectomy from September 2015 to May 2016 were included. INTERVENTIONS: Preoperative pelvic US was performed 2 weeks before surgery. MEASUREMENTS AND MAIN RESULTS: Among the 101 women enrolled in this study, preoperative US correctly identified the number of myomas in 73 patients (72.3%). A total of 208 myomas were preoperatively identified by US; 197 (94.7%) were surgically removed, and 11 (5.3%) were not visualized during laparoscopic myomectomy. The 11 undetected myomas were intramural (International Federation of Gynecology and Obstetrics [FIGO] type 3 and 4), with a mean diameter of 19.05 ± 5.91 mm. The type, site, and location of the 197 myomas identified by US preoperatively and removed via laparoscopy were confirmed at surgery in 78.7% (155/197), 80.7% (159/197), and 84.3% (166/197) of the cases, respectively. Two-hundred fifty-four total myomas were removed laparoscopically; 197 (77.6%) were preoperatively identified by US, and 57 (22.4%) were missed by US, having had a mean diameter of 13.51 ± 7.84 mm and predominantly being the subserosal type (FIGO type 5, 6, and 7) (57.9%, p < .05). CONCLUSION: Pelvic US is a valuable tool in preoperative evaluation and should be systematically performed when planning laparoscopic myomectomy.

Mioma vaginal / Vaginal mioma

Los leiomiomas, también llamados miomas o fibromas, son tumores del músculo liso que puede localizarse en cualquier parte del cuerpo, pero más comúnmente en los tractos genital y gastrointestinal. El objetivo del trabajo es presentar un caso de mioma vaginal en una mujer de 42 años. La paciente acudió a la consulta por presentar, desde hace varios meses, una masa redondeada, indolora y de crecimiento gradual, a nivel del introito vaginal. Se constata, mediante examen clínico e imagenológico, la presencia de una tumoración redondeada de implantación sésil, en la cara anterior de la vagina. Fue realizada la exéresis quirúrgica, la cual se envió para un estudio histopatológico. Se comprobó que se trataba de un leiomioma de la vagina. La paciente no presentó complicaciones posoperatorias(AU)

Leiomyomas, also called myomas or fibroids, are smooth muscle tumors that can be located anywhere in the body, but more commonly in the genital and gastrointestinal tracts. The objective of the paper is to present a case of vaginal myoma in a 42-year-old woman. This patient came to the consultation for presenting a painless gradually-growing round mass at the level of the vaginal introitus, for several months. The presence of a rounded mass of sessile implantation on the anterior side of the vagina is confirmed by clinical and imaging examination. Surgical exeresis was performed, which was histopathologically studied. It was found to be a vagina leiomyoma. The patient did not present postoperative complications(AU)

Portomesenteric Vein Thrombosis After Excision of Parasitic Peritoneal Myomas.

An enlargement of multiple asymptomatic pelvic masses was detected during a regular checkup of a 39-year-old woman. Twelve years earlier, she had undergone laparoscopic-assisted myomectomy, at which time an uncontained manual extraction of a posterior intramural myoma was performed. This was followed by 2 uneventful cesarean deliveries after spontaneous conceptions. Diagnostic imaging revealed at least 3 abdominal masses, 1 of which received its major blood supply from the inferior mesenteric artery. Gasless single-port laparoscopic excision of the peritoneal masses, was performed along with laparoscopic-assisted vaginal hysterectomy and bilateral salpingo- oophorectomy. The masses were histopathologically diagnosed as parasitic peritoneal myomas. The patient's immediate postoperative course was uneventful; however, on day 6 after surgery, she complained of severe periumbilical abdominal pain and vomiting. Anticoagulant therapy was initiated after hematologic examination revealed an elevated D-dimer level and dynamic computed tomography angiography showed portomesenteric vein thrombosis. Vaginal stump bleeding, which occurred 17 days after the initiation of anticoagulant therapy, was managed conservatively, and there was no recurrence of venous thrombosis in the year after surgery. To avoid significant morbidities and potential mortality when parasitic peritoneal myomas with aberrant neovascularization are excised, attention should be given to the perioperative development of venous thromboembolic events in rare locations.

Miomectomía en gestante de 14 semanas: a propósito de un caso / Myomectomy in a 14-week pregnant woman: about a case

ANTECEDENTES: La prevalencia de los miomas uterinos en la gestación es de 0,3 a 2,6% de los cuales un 10% se complican durante el embarazo. El manejo quirúrgico de los miomas en la gestación se reserva solo para los casos complicados. CASO CLÍNICO: Paciente de 36 años, primigesta, que consulta a las 11 semanas de gestación por cuadro de distensión abdominal, edema en extremidades inferiores y sangrado vaginal escaso. El examen físico y la ecografía evidencia un mioma de 23 cm de diámetro y saco gestacional con embrión vivo a nivel de hipocondrio izquierdo. En controles posteriores la paciente empeora clínicamente debido al crecimiento del mioma, presentado dolor abdominal intenso, aumento de edemas en ambas extremidades inferiores. Los estudios de imagen informan ectasia pielocalicial bilateral y compresión de venas ilíacas. Ante los hallazgos y clínica se realiza miomectomía sin incidencias a las 14 semanas de gestación. El postoperatorio y controles posteriores son normales y se programa cesárea a las 37 semanas de gestación. DISCUSIÓN: La miomectomía en la gestación conlleva riesgos de hemorragia y aborto. Se reserva para casos puntuales que no respondan al manejo expectante. La recomendación actual y la experiencia indican que se debe realizar en el segundo trimestre de gestación. CONCLUSIÓN: La miomectomía en la gestación es una técnica que se debe plantear en casos seleccionados y que presenta pocas complicaciones.

BACKGROUND: The prevalence of uterine fibroids in pregnancy is 0.3 to 2.6%, 10% of which complicate during pregnancy. The surgical management of fibroids in pregnant women is reserved for complicated cases. CASE REPORT: The patient is 36 years old, first pregnancy, consulting at 11 weeks of gestation with bloating, edema in the lower extremities and mild vaginal bleeding. Physical examination and ultrasound evidence a 23 cm diameter fibroid and gestational sac with live embryo in the left upper abdominal quadrant. In subsequent tests the patient worsens clinically due to fibroid growth, presenting intense abdominal pain, increased edema in both lower extremities. Imaging studies report pyelocalyceal bilateral ectasia and compression of iliac veins. Given these findings and symptoms a myomectomy is performed without incidents at 14 weeks of gestation. Postoperative and subsequent tests are normal and caesarean section is preformed at 37 weeks of gestation. DISCUSSION: myomectomy in pregnancy carries risks of bleeding and abortion. It is reserved for cases that do not respond to expectant management. The current recommendation and experience indicate that it has to be performed in the second trimester. CONCLUSION: Myomectomy in pregnancy is a technique that should be considered in selected cases and has few complications.

Iatrogenic parasitic myoma on the peritoneum of the right pelvic wall.

Uterine myoma, the most common form of uterine tumor, occurs in approximately 25% of reproductive-aged women. Parasitic myoma, which outgrows its uterine blood supply and obtains a secondary blood supply from another organ such as the omentum, is rare. It is extremely rare if it is on the peritoneum of the right pelvic wall. Only a few cases have been found in this location so far. Here, the authors report an interesting case of parasitic myoma on the peritoneum of the right pelvic wall. They conclude with seven key points, which should be paid more attention to avoid iatrogenic parasitic myoma.