Fibroid surgery and morcellation — structured oral station (12 minutes)

Opening prompt — "Justify the operative plan"

Model response: [1][4]

• "The FIGO type 1 submucosal fibroid goes to hysteroscopic myomectomy — cavity access, controls the bleeding, improves fertility, uterus-sparing. The three FIGO type 4 intramural fibroids go to laparoscopic myomectomy with multi-layer closure."
• "The route follows the FIGO type: 0 to 2 hysteroscopic, 3 to 7 laparoscopic or open, hysterectomy when the family is complete. She is family-incomplete, so uterus-sparing throughout."[1]

Probe 1 — "How will you get the specimen out, and what governs that?"

• "By power morcellation with an in-bag containment system. RANZCOG C-Gyn 33 governs this: morcellation only with no suspicion of malignancy (including atypical endometrial hyperplasia), an in-bag containment system, and a credentialed operator — generally AGES-RANZCOG Level 5 and above."[1]

Probe 2 — "She is 38 and wants another baby. Is there no risk?"

• "There is no reliable pre-operative test for leiomyosarcoma — incidence 0.36 to 1.8 per 100,000 woman-years, and the risk of diagnosing LMS after presumed-fibroid surgery is 0.01 to 0.08 per cent. I exclude suspicion clinically and on MRI, use contained extraction, and consent her on the occult-sarcoma risk."[1]

Probe 3 — "A colleague suggests UAE instead. Do you agree?"

• "UAE is uterus-sparing with faster recovery — the REST trial showed a 1-day versus 5-day stay. But about a third of women having UAE need a hysterectomy within ten years (EMMY 35 per cent), and effects on fertility and pregnancy are uncertain. RANZCOG does not recommend routine UAE in young patients wishing to conceive. For her, myomectomy is the fertility-preserving choice; UAE would be a trial-setting discussion only."[2][3][4]

Probe 4 — "She asks what the operation means for her next pregnancy"

This is a scored communication domain — demonstrate it out loud: [1]

• "There is a real risk of uterine rupture in a future pregnancy after myomectomy, and we will discuss the safest way for you to deliver. I will use meticulous multi-layer closure to minimise scarring, and I want you to tell your obstetric team about this operation in any future pregnancy."
• Offer a clear plan, a timeline, and a named contact between visits.[1]

Probe 5 — "How would your plan change if she were 58 and postmenopausal with a rapidly growing fibroid?"

• "A rapidly growing fibroid postmenopause is leiomyosarcoma until proven otherwise. I would arrange MRI with diffusion-weighted imaging and endometrial sampling, plan en-bloc removal, avoid morcellation, and involve gynaecological oncology. The contained-morcellation plan is only for the no-suspicion case."[1]