Robotic Resection of a Large Degenerating Leiomyoma
The 56-year-old, multiparous, post-menopausal woman presented with a cystic left adnexal mass found incidentally on her yearly transvaginal ultrasound to monitor fibroids. She had a known history of uterine leiomyomas for which she had not required treatment. Her only previous abdominal surgery was a tubal ligation. Pelvic examination demonstrated a mobile, non-tender uterus with a large palpable left adnexal mass that was smooth and mobile. A transvaginal ultrasound demonstrated a heterogenous fibroid uterus. The ovaries were unable to be visualized. Bilateral soft tissue adnexal masses were present with an undetermined nature and no vascularity. Pelvic MRI demonstrated numerous uterine fibroids as well as a large, heterogeneously T2 hyperintense lesion within the left pelvis measuring approximately 10.5 × 17.5 cm. This mass was found to be situated posteriorly into the presacral space and extended anteriorly to the anterior lower abdominal wall. The left anterior aspect of this lesion appeared to be intimately associated with the left ovary. There was also T2 hyperintense material extending throughout the anterior pelvis both left and right. The margins of this collection demonstrated a thin rim of enhancement and there appeared to be a heterogeneous, relatively nodular enhancement within the left anterior lower pelvic component. Subsequent computed tomography (CT) scan of the abdomen and pelvis with and without contrast demonstrated a large complex cystic mass extending throughout the pelvis measuring 17.1 × 15.5 × 11.9 cm; it was suspected to be arising from the left adnexa. Tumor markers including CA 125, CEA, and CA 19-9 were normal.

Surgical intervention was planned due to imaging findings. Upon laparoscopic abdominopelvic surveillance, no ascites was noted; Liver, stomach, omentum, and diaphragm all appeared normal. The uterus was enlarged with multiple fibroids. Right fallopian tube and ovary were normal. An elongated cystic, loose, soft mass was noted in the left pelvis extending to the anterior abdominal wall. A normal appearing left ovary and fallopian tube connected to the mass posteriorly. The mass extended in the retroperitoneal space along the left sidewall to the para-vesicle space. The mass was meticulously dissected from the rectosigmoid colon, left ureter and left sidewall to the para-vesicle space, completing dissection off the bladder. The remainder of the bilateral salpingo-oophorectomy and hysterectomy was performed in the usual fashion. Uterus, fallopian tubes, ovaries, and mass were removed from the abdomen via colpotomy. The patient did well postoperatively and was discharged home the same day without complication.

Specimen of pelvic mass, uterus, cervix, fallopian tubes, and ovaries weighed 1072.2 g. The collapsed cystic mass measures 12.5 × 12.5 × 3.0 cm and has a pink, glistening, soft, ragged, partially ruptured external surface. Sectioning of the cystic structure reveals tan-yellow, mucoid cut surfaces, with no discrete firm masses or papillary excrescences grossly identified. The endometrial cavity is normal-appearing with no involvement with the cystic structure. The final pathology was consistent with leiomyoma with degenerative changes.