In a symptomatic woman who wishes to preserve fertility, how should a broad‑ligament fibroid be evaluated and managed?

Management of Broad Ligament Fibroids in Symptomatic Women Desiring Fertility Preservation

For a symptomatic woman with a broad ligament fibroid who wishes to preserve fertility, surgical myomectomy is the definitive treatment approach, as these rare extrauterine fibroids require careful preoperative imaging and meticulous surgical technique to avoid injury to the ureters and pelvic vasculature. 1, 2, 3

Diagnostic Evaluation

Initial Imaging Assessment

• Pelvic ultrasound with Doppler is the first-line diagnostic modality, achieving 90-99% sensitivity for fibroid detection, though broad ligament fibroids may appear as masses separate from the uterus. 2
• MRI is superior for delineating the exact location, size, and relationship to surrounding structures, which is critical for surgical planning in broad ligament fibroids given their proximity to ureters, iliac vessels, and bladder. 1, 2, 4
• CT pelvis may be warranted if calcification is suspected, as it better characterizes calcified components that would impact treatment responsiveness. 5

Key Diagnostic Features to Identify

• The cervix is typically deviated and elevated but separable from the mass on bimanual examination. 6
• The fibroid extends laterally into the broad ligament rather than arising from the uterine corpus, distinguishing it from typical intramural or subserosal fibroids. 3, 4
• Assess for hydronephrosis or ureteral deviation on imaging, as broad ligament fibroids commonly compress the ureter. 4, 6

Treatment Algorithm for Fertility Preservation

Surgical Myomectomy: The Primary Approach

Laparoscopic or open myomectomy is the appropriate fertility-preserving treatment, with the surgical approach determined by fibroid size and anatomical complexity. 1, 2

Surgical Planning Considerations

• For broad ligament fibroids >10 cm or those with deep pelvic extension, open laparotomy is typically required due to the need for meticulous dissection around vital structures. 6, 7
• Preoperative ureteral stent placement should be considered to facilitate intraoperative identification and avoid ureteral injury during dissection. 4, 6
• The surgical approach involves careful identification of the ureter and iliac vessels before attempting fibroid enucleation, as these structures are often displaced or adherent to the fibroid capsule. 4, 6

Critical Surgical Pitfalls

• Significant intraoperative blood loss is a major risk given the proximity to major pelvic vessels and the rich vascular supply within the broad ligament. 2, 6
• Postoperative adhesion formation may affect future fertility, particularly if extensive peritoneal dissection is required. 2
• Bladder and bowel injury can occur when large broad ligament fibroids are densely adherent to these structures. 7

Preoperative Medical Therapy

GnRH agonists (leuprolide) or antagonists (elagolix, relugolix) may be used preoperatively to reduce fibroid size and minimize surgical blood loss, though the volume reduction achieved (typically 30-50%) may be modest for large broad ligament fibroids. 5, 2

Why Other Treatments Are Not Appropriate

Uterine Artery Embolization (UAE)

UAE is not recommended for broad ligament fibroids because these extrauterine fibroids often have aberrant blood supply from ovarian or other pelvic arteries rather than the uterine arteries, making embolization technically challenging and less effective. 1, 2

Hysteroscopic Myomectomy

Hysteroscopic myomectomy is not applicable as broad ligament fibroids are extrauterine and not accessible via the transcervical route. 1

MR-Guided Focused Ultrasound (MRgFUS)

MRgFUS is not suitable for broad ligament fibroids due to their location outside the uterus and proximity to bowel and other structures that would be in the acoustic pathway. 2

Medical Management Alone

Medical therapy alone is insufficient for definitive management of symptomatic broad ligament fibroids, as these medications do not eliminate the mass and symptoms typically recur after discontinuation. 5, 2

Postoperative Counseling

• Fibroid recurrence rates after myomectomy range from 15-30% over 5 years, though specific data for broad ligament fibroids is limited given their rarity. 2
• Pregnancy should be delayed 3-6 months post-myomectomy to allow adequate uterine healing, particularly if the myometrium was entered during dissection. 2
• Future pregnancies may require cesarean delivery if the myomectomy involved extensive uterine wall reconstruction. 2