Based on immunohistochemical findings, it is proposed to remove fibroids in women seeking pregnancy whilst respecting the pseudocapsule by neurofibre sparing in the incision site. We published that this is of utmost importance for optimal muscular healing and myometrial function in future pregnancies. In fibroids detected under a size of 5–6 cm in diameter especially in young women wanting to achieve pregnancies, the myomectomy should be performed before the myoma reaches a size causing compression of the surrounding tissues and uterine distortion, which may result in the loss of regenerative potential [43].

It is good surgical and clinical practice to perform a hysteroscopy before advancing to the laparoscopic myomectomy. The advantage of the hysteroscopy is that, as this is a patient seeking fertility, endometrial pathology can be identified and corrected and intra-cavity extension of the fibroid can be noted. A chrompertubation should be performed before proceeding to the myomectomy. It is advisable to use a uterine manipulator to stabilize the mobile uterus during a myomectomy.

A longitudinal incision is usually preferred on the uterus for a myomectomy but, if the myoma extends laterally, a horizontal incision is also acceptable. If the uterine cavity is entered during the procedure, it just has to be sutured additionally in a special layer. If the fibroid is posterior, there might be an increased risk of adhesion formation and an anti-adhesive strategy needs to be adopted. The patient should always be informed that there might be a rare possibility to convert the surgery to a laparotomy.

The Practice Committee of the American Society for Reproductive Medicine in collaboration with The Society of Reproductive Surgeons concluded that Myomectomy is a relatively safe surgical procedure associated with few serious complications. However, postoperative adhesions are common after abdominal myomectomy and pose a significant potential threat to subsequent fertility. Hence, a laparoscopic and/or hysteroscopic myomectomy should be preferred to an abdominal. However, each surgeon should determine his or her own criteria for laparoscopic myomectomy.

Post-surgery, the patient is usually advised to attempt pregnancy after 3 months to give adequate time for the uterine scar to heal.

Figures 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, and 5.8 give a detailed diagnostic and surgical description of myomectomy and surgical reconstruction of the uterine wall.

This step wise description of laparoscopic myoma enucleation as an intracapsular approach with an adequate reconstruction of the uterine wall gives the patients a good start for further fertility results. The adaption of wound edges may be in one, two or three layers depending of the situation. If the uterine cavity has been opened, an extra layer of sutures has to be applied. Conventional or barbed sutures are acceptable.

Submucous myomas may cause serious implantation problems and raise the frequency of abortions. The best time of surgery is the early phase in the cycle without bleeding. Saline Infusion Sonography best reveals the fibroid enucleation level and helps to plan the correct surgery which sometimes needs to be combined with a laparoscopic approach [8].

A 26-year-old Caucasian woman, nulliparous, was transferred for surgery with a recurring symptomatic ovarian cyst. During the gynecological examination, in addition to an unsuspicious-looking cyst on the left ovary, a 2.1 cm diameter well-circumscribed uterine mass located in the posterior wall of the fundus, 1.2 cm from the serosal surface was recorded as a fibroid (Fig. 5.9). This known tumor had been seen by an ultrasound scan 1-year earlier measuring 1 cm in diameter. The patient had a medical history of three laparoscopic surgeries for the enucleation of relapsing functional ovarian cysts with no evidence of endometriosis.

The patient required a fourth laparoscopy to treat the symptomatic ovarian cyst. Because of the growth of the tumor on the posterior wall, the age of the patient and possible problems in future family planning, it was decided to simultaneously excise the suspected myoma. At laparoscopy, the ovarian cyst was enucleated and the presumed fibroid was resected. Excision of the tumor was difficult as it was smoother than a typical myoma and more difficult to grasp with forceps. The tumor was enucleated with a special instrument which we also use to remove myomas. The usual enucleation performed in fibroid surgery was not possible as there was no capsule separating nodule from the myometrium and the tumor seemed to grow into the orthotope myometric tissue (Fig. 5.10a). After removal of the nodule and the surrounding myometrial layer, the uterine wall was reconstructed in a single layer with reversed and inverted single stitches (Fig. 5.10b). The tumor was removed after intraabdominal morcellation (Fig. 5.10c).

A 19-year-old nulligravida presented with pain in the lower abdomen for the last 6 months, dyspareunia and pain in the back. Transvaginal ultrasound revealed a well-circumscribed 5 cm mass in the fundus of the uterus. No additional lesions were noted in the pelvis. The patient underwent an uneventful laparoscopic procedure with excision of the tumour and reconstruction of uterus wall.

The post-operative recovery was in each case unremarkable and the patients were discharged 2 days after surgery free of pain. The follow-up period was without pathological findings.

Histological tissue was available from both original tumor specimens. Routine histological studies were performed according to the usual procedures: 4-μm thick sections of formaldehyde-fixed, paraffin-embedded tissue were stained with hematoxylin and eosin (H&E) for the light microscopic histological examination. Immunohistochemistry was performed using the following antibodies: calretinin for staining cells of mesothelial origin and CD34 for marking endothelial cells, KI-67 was used as a proliferation marker [47, 52].

Macroscopically, both tumors showed a white-grey, nodular, non-capsulated surface. The histological examination showed smooth muscle cells of normal myometrium and in between the myometrium tumor elements consisted of slit-like, tubular, cystic or cribriform anastomosing gland-like spaces reminiscent of vascular structures (Fig. 5.11a, b). The lining cells were columnar, cuboidal to flat with bland cytologic features and mitotic activity. The angiomatoid spaces were lined by a single layer of flattened cells with oval or round nuclei, divided by fine connective tissue septa rich in blood vessels with a slight lymphocytic infiltration. The spaces contained cells with slightly eosinophilic cytoplasm and prominent cytoplasmic vacuoles that mimic signet ring cells. The pseudoglandular spaces were surrounded by hyperplastic smooth muscle with a sprinkling of stromal lymphocytes. Nuclei were usually small with inconspicuous nucleoli. Neither atypical nuclei, mitoses or necrosis were found.

Immunohistochemical techniques showed a strong staining of tumor cells with calretinin but no staining with CD34 (Fig. 5.11c, d). However, CD34 marked the endothelial cells and the surrounding orthotopic lymphovascular vessels (Fig. 5.11e, f). The Ki-67 index of the tumor cells was <1 % (Fig. 5.11g).

Adenomatoid tumors occur most commonly during the reproductive years. Nevertheless, they are rare, benign neoplasms, occurring in about 1 % of pathologically examined hysterectomies and are mostly incidental findings [45, 53]. In the majority of the known case reports the diagnosis is made only after pathological examination of other suspected tumor origins. As in our case, most of the adenomatoid tumors remain asymptomatic. Adenomatoid tumors of the uterus can be either subserosal or intramural and can involve the subendometrial myometrium. Due to their anatomical localization, the most common symptoms are pain and menorrhagia or symptoms associated with adenomyosis uteri. Many cases of incidental diagnosis do not show any clinical symptoms at all [45, 46, 52, 54–56]. In females, adenomatoid tumors are mostly situated in the fallopian tubes and the uterus, and less frequently in the ovaries or the periovarial tissue. In males, they occur in the epididymidis, tunica albuginea and testicular parenchyma. Very seldom, adenomatoid tumors are seen in extragenital regions e.g. adrenal gland, omentum majus or liver. Accordingly, the clinical symptoms are similar to those caused by other benign space-consuming lesions in these regions. There is no evidence of recurrence, malignant transformation or metastasis [46].

In the majority of cases preoperative detailed differential diagnostics are the exception as adenomatoid tumors are found incidentally. Despite the well-established microscopic features that distinguish adenomatoid tumors from all other entities, preliminary clinical examination, ultrasound or MRI cannot differentiate adenomatoid tumors from their differential diagnosis [52, 56, 57].

The dissimilarity to uterine fibroids, the most frequent misdiagnosis of uterine adenomatoid tumors, is seen in the intraoperative complexity of the separation between tumor and myometrium. Mitsumori et al. report two cases of adenomatoid tumors of the uterus that also imitated leiomyoma and were only diagnosed postoperatively [57]. Histologically, fibroids have their own capsule of connective tissue. This is missing in adenomatoid tumors [49] and it is, therefore, necessary to include a layer of unaffected myometrium when operating adenomatoid tumors. Nevertheless, laparoscopic surgery for the treatment of adenomatoid tumors is feasible and recommended. In contrast to adenomyosis uteri, there is no histological infiltration of endometrial glands and stroma into the myometrial tissue. Adenomyosis uteri in its primary and disseminated forms, infiltrates the entire myometrial wall. A more disseminated spreading of adenomatoid tumor has been reported in women with immunosuppression [58].