Surgical management of neurovascular bundle in uterine fibroid pseudocapsule

Abstract

The uterine fibroid pseudocapsule is a fibro-neurovascular structure surrounding a leiomyoma, separating it from normal peripheral myometrium. The fibroid pseudocapsule is composed of a neurovascular network rich in neurofibers similar to the neurovascular bundle surrounding a prostate. The nerve-sparing radical prostatectomy has several intriguing parallels to myomectomy. It may serve either as a useful model in modern fibroid surgical removal, or it may accelerate our understanding of the role of the fibrovascular bundle and neurotransmitters in the healing and restoration of reproductive potential after intracapsular myomectomy. Surgical innovations, such as laparoscopic or robotic myomectomy applied to the intracapsular technique with magnification of the fibroid pseudocapsule surrounding a leiomyoma, originated from the radical prostatectomy method that highlighted a careful dissection of the neurovascular bundle to preserve sexual functioning after prostatectomy. Gentle uterine leiomyoma detachment from the pseudocapsule neurovascular bundle has allowed a reduction in uterine bleeding and uterine musculature trauma with sparing of the pseudocapsule neuropeptide fibers. This technique has had a favorable impact on functionality in reproduction and has improved fertility outcomes. Further research should determine the role of the myoma pseudocapsule neurovascular bundle in the formation, growth, and pathophysiological consequences of fibroids, including pain, infertility, and reproductive outcomes.

Figure 1.

Histological microphotograph stained by hematoxylin & eosin (H&E) at 10x, showing the myometrium of a pseudocapsule with vascular spaces: A=myometrium, B=pseudocapsule, C=leiomyoma.

Figure 2.

A uterine transvaginal ultrasound section evidenced the fibroid pseudocapsule by a “ring of fire” around the fibroid.

Figure 3.

An intraoperative image of laparotomic myomectomy showing a fibroid pseudocapsule during myoma stretching by the surgeon from myometrium.

Figure 4.

A laparoscopic radical prostatectomy image by da Vinci robot, showing the prostatic vein and neurovascular bundle surrounding the prostate.

Figure 5.

A laparoscopic image showing fibroid enucleating from myometrium by monopolar Hook electrode gentle cut of pseudocapsule by low-wattage energy, to expose the myoma surface, with a magnification of the pseudocapsule during myoma removal.