Case presentation
A 46-year-old Gravida 3 para 3 woman with no medical, allergy, and drug use history and with a history of abdominal pain, hypermenorrhea, and pelvic pressure was referred to the gynecology and oncology ward of a university Hospital a few months ago. In the vaginal exam, there was bulging in the right side, which completely deviated the cervix to the left and upward position. On abdominal sonography, the uterus size was 63*42 mm with an endometrial thickness of 9 mm. A heterogeneous 114*99-mm mass in a posterior cul-de-sac, probably with the uterine origin, was detected. Magnetic Resonance Imaging (MRI) revealed a well-defined heterogeneous soft-tissue mass from degeneration and necrosis in the pelvic cavity posterior to the uterus was observed and separated from the uterus and ovaries. In post-contrast images, heterogeneous enhancement at the tumor was noticed (Figures 1&2). This mass lesion posed pressure on the right ureter, causing hydroureteronephrosis, and was in close contact with the right external iliac vein (Figure3). She had a surgical history of cesarean section withpfannenstiel incision for three times, and her last child was ten years old. The attempts for ureteral stent placement before surgery had failed; hence, she was scheduled for surgery. The surgery was performed by the fellows of oncogynecology under the direct supervision of their attending surgeon. She underwent an exploratory laparotomy under the general anesthesia by a midline incision on the suspicion of leiomyoma. A huge solid retroperitoneal mass (16*12*11 cm) was detected in the right broad ligament, which was attached to the pelvic floor and seemed to be separated from the uterus. Surgical excision aimed to resect the tumor completely. Because of the dense adhesion of the tumor to the ureter and vessels, the internal iliac vein and ureteral injury were torn during dissection. The internal iliac vein was repaired by a vascular surgeon. The intraoperative frozen section analysis suggested smooth muscle tumor without determining its being benign or malignant. Hysterectomy and bilateral salpangectomy was performed, and the ovaries were preserved.
An internal ureteral DJ stent was inserted, and the primary ureteral was repaired by the urologist. After consulting with an anesthesiologist, we transfused three-unit Pack Cell to the patient during the operation due to blood loss. The oral diet began one day after surgery, and the patient was discharged 72 hours after admission. Before surgery, Hb was 10.5, and the patient was discharged with Hb=9.8. Ureteral DJ was removed six weeks later with no complication. Pathologic examination revealed grade II / III LMS with the mitotic rate of 12 / 10 HPF, including atypical forms. Necrosis extent was <50%, and the margin could not be assessed. The pathologic stage was pT4. The patient was a candidate for radiation; hence, external beam radiotherapy was provided for her for 25 sessions.