Temporary endovascular balloon occlusion of the bilateral internal iliac arteries for control of hemorrhage during laparoscopic-assisted myomectomy in a nulligravida with a large cervical myoma  Akihiro Takeda, M.D., Kazuyuki Koyama, M.D., Sanae Imoto, M.D., Masahiko Mori, M.D., Kotaro Sakai, M.D., Hiromi Nakamura, M.D.  Fertility and Sterility  Volume 91, Issue 3, Pages 935.e5-935.e9 (March 2009) DOI: 10.1016/j.fertnstert.2008.09.040 Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions

Figure 1 (A) Sagittal T2-weighted magnetic resonance image of a large cervical myoma growing in the retrovesical space. Behind the cervical myoma the normal portion of uterine corpus (arrow) was present with elongated cervical canal. This image was obtained 1 month after GnRH agonist administration. (B) Axial T2-weighted magnetic resonance image of a large cervical myoma occupying the pelvic cavity. (C) Computed tomographic angiography before myomectomy showed prominent vascularization of the myoma tissue originating from the left uterine artery (arrow). Upward dislocation of the left uterine artery was also noted. (D) Balloon occlusion of the left internal iliac artery with a right common femoral artery approach. Injection of contrast material with the balloon inflated (arrow) demonstrated stagnant flow. Vascular distribution to the myoma node to be occluded during myomectomy was also visualized (arrowhead). Fertility and Sterility 2009 91, 935.e5-935.e9DOI: (10.1016/j.fertnstert.2008.09.040) Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions

Figure 2 (A) A large cervical myoma was dissected with upward traction. (B) Uterine wall and vesicouterine peritoneal defect after enucleation of the large cervical myoma were reapproximated by two-layered suturing. (C) View of lower abdomen at the end of surgery. A J-Vac drain was placed through a 12-mm port at the right lateral side of the umbilicus. Bilateral ureteral stents and bilateral inguinal vascular sheaths for the occlusion catheter are also seen. Incisional length of the suprapubic port was 3.5 cm. (D) A large cervical myoma weighing 1,036 g was extracted through a minimal incision after morcellation. Fertility and Sterility 2009 91, 935.e5-935.e9DOI: (10.1016/j.fertnstert.2008.09.040) Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions