Laparoscopic hysterectomy as optimal approach for 5400 grams uterus with associated polycythemia: A case report

BACKGROUND Uterine myomas are the most common benign gynecological soft tissue tumors in women but polycythemia associated with these tumors is rare. Polycythemia is significantly associated with risk of venous thromboembolism (VTE), which is further increased in case of a large pelvic mass and obesity. Here we report the surgical challenges in the case of an obese patient with a giant fibromatous uterus and associated polycythemia. CASE SUMMARY A 42-year-old obese woman was referred to our department for treatment for a huge fibromatous uterus. She suffered of pelvic pressure and abdominal distension and reported severe dyspnea from several months. Laboratory analyses including hemoglobin (Hb) 19.2 g/dL and hematocrit (Hct) 59.7% were indicative of polycythemia. Arterial blood gas analysis showed arterial oxygen pressure (pO2) of 81.5 mmHg. Abdominal computed tomography confirmed a giant fibromatous uterus measuring 28.2 cm × 17 cm × 25 cm. To reduce the thromboembolic risk, the patient underwent low molecular weight heparin, phlebotomy twice before surgery, and we opted for a laparoscopic hysterectomy. The uterus weighed 5400 g and the histology confirmed a diagnosis of leiomyoma. We did not find increased erythropoietin levels in the supernatant of the myomatous uterine tissue. There were no complications. On postoperative day 1, the Hb and the Hct levels normalized to 13.3 g/dL and 41.7%, respectively. Arterial blood gas analysis after surgery showed a pO2 of 144.7 mmHg. These results suggested the diagnosis of myomatous erythrocytosis syndrome. The patient was discharged on the second postoperative day in very good condition with no symptoms. CONCLUSION We believe this is the first reported laparoscopic hysterectomy in a patient with a giant uterus, polycythemia and obesity. Multiple VTE risk factors warranted a laparoscopic approach. Keywords: Hysterectomy, Laparoscopy, Myoma, Myomatous erythrocytosis syndrome, Polycythemia, huge uterus, Total laparoscopic hysterectomy, Case report Core tip: Uterine myoma are rarely associated with polycythemia. Here we report the challenging case of an obese patient with a giant fibromatous uterus and associated polycythemia; these factors increased significantly the risk of venous thromboembolism. To reduce such risk, we opted for a laparoscopic hysterectomy, which was preceded by phlebotomy. Laparoscopy was successfully completed without complications. The uterus weighed 5400 g. After surgery the patient’s hematological profile normalized. The final diagnosis was myomatous erythrocytosis syndrome (MES). To our knowledge, this is the first case of laparoscopic hysterectomy in an obese patient with a very large uterus and polycythemia due to MES.