A Case in Which Flexible Hysterofiberscopic Observation Was Useful for Removal of the Arm of a Levonorgestrel-releasing Intrauterine System That Had Pierced the Cervical Wall

INTRODUCTION The levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena 52 mg; Bayer, Whippany, NJ, USA)[1] is used worldwide for hypermenorrhea. However, the device may perforate the uterus and enter the abdominal cavity or partially penetrate the corpus of the uterus and cervix.[2] Hysteroscopic removal[3-5] is reported useful in a case involving penetration of the wall of the uterine cervix. OBJECTIVE The objective of this study was to demonstrate the usefulness of flexible hysterofiberscopic observation for the removal of the arm of a levonorgestrel-releasing intrauterine system (LNG IUS) that had pierced the cervical wall. DESIGN The arm was removed under observation with a video flexible hysterofiberscope (Olympus Visera HYF Type V Hysterovideoscope; Olympus Medical Systems Corporation, Tokyo, Japan)[6] and a slender straight Pean forceps.[7] PATIENT A 46-year-old unmarried, nonpregnant woman without any particular past history with complaints of hypermenorrhea and anemia elected to undergo insertion of an LNG-IUS. Two years later, the patient developed dark brown bleeding and visited our outpatient clinic. The lower end of the LNG-IUS was visible from the external uterine ostium. We attempted removal with a Pean forceps. Most of the LNG-IUS could be removed, but the left arm had pierced the cervical wall, leaving two-thirds of the arm in the cervix. We therefore decided to remove the arm in the operation room. Transvaginal ultrasound showed that the LNG-IUS was located 26.9 mm from the external uterine ostium. The arm had pierced the cervix in the 3-o'clock direction, and the length of the remaining arm was 10.4 mm. INTERVENTIONS The operative technique is shown in Figure 1 and Video (with some audio commentary and superimposed words). The white arm was found to be piercing the cervix and traversing the cervical canal. At the anterior to the LNG-IUS and posterior, there was adequate space for the hysterofiberscope (HF) with a tip diameter of 3.8 mm to advance into the uterine cavity. No significant changes were found in the uterine cavity. When a slender Pean forceps (tip width: 3 mm) was opened anteriorly and posteriorly, it created a space in which the tip of the Pean was sufficient to hold the LNG-IUS. During the grasping operation, the forceps holding the anterior lip of the portio was changed to a Martin single-hook forceps, making it possible to maximally open the tip of the Pean. The HF and Pean forceps interfered with each other, making it difficult to observe both the open-tipped Pean and the LNG-IUS. Grasping the anterior lip of the portio with the Martin, and by a blind operation, the Pean forceps was opened anteriorly and posteriorly as much as possible, and an attempt was made to pinch the arm at 26.9 mm from the tip of the uterine vaginal part. When a pinching sensation was felt, the operator gently gripped the arm to avoid crushing it. With coordinated manipulation of the Martin and Pean, the arm was removed from the cervical wall like pulling out a nail from a board. We pulled the arm from the cervical wall and removed it from the uterus. HF examination was then performed in the cervical canal and uterine cavity. The site at which the LNG-IUS had pierced the cervical wall exhibited no bleeding or hole formation.Figure 1: The left arm of the Levonorgestrel (LNS)-intrauterine system was found to be penetrating the left wall of the cervix in the 3-o'clock direction http://www.apagemit.com/page/video/show.aspx?num=314&kind=2&page=1CONCLUSION Preoperative ultrasound and intraoperative hysteroscopic observation were considered essential to successful arm removal by fully understanding the position and condition of the arm within the cervix. To avoid damaging the fiberscope, it is important to insert the Pean forceps into the cervical canal first and then operate them under direct observation. Ethics statement The reporting of this case was approved by the Meiwa General Hospital Ethics Committee. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Author contributions All persons have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. All relevant information and findings are included within the article itself. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.