She was Mrs. CL, 39 years old; housewife, nulligeste, nulliparous and with no known medical history. She had benefited from an outpatient consultation at the obstetrics and gynecology department of the Mali Hospital on August 24, 2022 for pelvic mass and cycle disorder.

The history of the disease goes back several months marked by a gradual increase in the size of the abdomen to the chest. No medical investigation had been carried out before. However, she had been undergoing traditional treatments for years since she lives in a rural area very far from specialized health facilities. Given the impressive increase in the volume of the abdomen, she was referred to us by a general practitioner at the community health center in her locality for treatment.

The physical examination examined the following parameters:

Consciousness: lucid, with a good general condition;Conjunctiva: coloured; Blood pressure: 110/07 mm Hg, with a heart rate rated at 80 beats/minute;Palpation: a voluminous abdomen, with a long longitudinal axis measuring 36 cm with a tape measure;In the speculum: a healthy-looking cervix with some physiological leucorrhoea, On vaginal examination: a mid-length posterior cervix, a large uterus that can be mobilized without adnexal sensitivity.The examination of the other organs was unremarkable. Screening with visual inspection techniques: VIA/LVI/which was negative

At the end of this examination, we mentioned three diagnostic hypotheses, namely:

A giant fibroid. A large ovarian cyst with an organic appearance.Uterine sarcoma

A pelvic-abdominal ultrasound was requested which objectified: a voluminous abdominal-pelvic mass at the expense of the uterus measuring 30cm in long axis. The uterus bore at least eleven (11) fibromatous nuclei scattered over the uterine body. The mapping was as follows: submucosa, interstitial and subserosus. The largest were corporeo-isthmian. There was a ureter-hydronephrosis by compression of the ureters ().

Figure 1. Ultrasound images of a polymyomatous and empty globular uterus.

Figure 2. Abdominal CT scan; sagittal and axial reconstruction objectifying a mass related to polymyomatous globular uterus.

An additional thoraco-abdominopelvic CT scan that had been performed and objectified ().

The thoracic stage was unremarkable,The abdominal level: stage I bilateral hydronephrosis due to compression The pelvic floor: a globular polymyomatous uterus with abdominal expansion, achieving a mass effect on the digestive structures. It contains several fibromatous nuclei of varying size and location, the largest of which measured 15 × 14 cm

Considering the imaging and clinical results, a surgical decision was proposed and accepted by the patient.

The pre-operative assessment including:

Rhesus grouping: A rhesus positive Complete blood count: 12 g/dl hemoglobin level, with no other particularities on the blood count,Bleeding time, coagulation time, uratemia, serum creatinine, blood glucose, HIV serology: no particularity.The tumor markers: alpha-fetoprotein (AFP); tumor antigen 125 (CA 125); carbohydrate antigen 19-9 (CA 19-9); carcinoembryonic antigen (CEA): were unremarkable.

On the basis of the clinical and paraclinical examination and the paraclinical investigations, an indication for polymyomectomy was made after a multidisciplinary consultation of the various providers (surgeons, gynaecologists, anaesthetists, operating room nurses, the blood bank). The patient accepted the recommendations and honoured the commitments for this surgery.

The surgery was scheduled and performed on September 6, 2022.

General anesthesia was therefore decided and a preoperative fasting of 10 to 12 hours before admission to the operating room.

After installation and observation of the checklist on the operating table.

We proceeded:

A smearing and placement of the various operating drapes and the placement of an indwelling urinary catheter. A median incision above and below the umbilical was made which objectified: On celiotomy, a large polylobed uterus measuring about 30 to 32 centimeters in its long axis is discovered containing several fibroid drownings, including a pedicled nucleus of about 6 centimeters in diameter.The placement of a tourniquet in the isthmic zone was performed in order to minimize blood spoliation during the duration of the enucleation of the fibroid nuclei The annexes were unremarkable. We had made a longitudinal incision of 25 cm, going from the cervico-isthmic region to the uterine fundus. This incision allowed us to enucleate two large blocks of fibromatous nuclei, each measuring between 15 and 20 cm in diameter and a pedicled nucleus of 6 cm in diameter. During the enucleation of the fibroid nuclei, we accidentally opened the uterine cavity which was carefully repaired (iatrogenic intrusion). We proceeded to padding the uterine margins in two planes over 25 cm with Vicryl wire crimped 0 and 1 in separate points.A careful abdominal cleansing was done with saline The closure of the different layers was done in the following way: an overlock on the peritoneum and the aponeurosis respectively with the Vicryl 2/0 and 1 threads; followed by the bringing together of the four separate points. Also the abdominal wall was closed by simple separate stitches followed by the dressing. (Op block figure) ().

Figure 3. Pre- and post-myomectomy photographic images.

Postoperatively: urine was clear, blood spoliation was minimal about 150 ml; postoperative blood pressure was 100/06 mm Hg, No pre- and post-operative blood transfusion. The 03 blocks of fibromatous nuclei weighed 4200 g.

The post-operative effects were simple.

The patient was discharged after 03 days of surgery.

Abdominal-pelvic masses are common in some African settings, taking into account socio-cultural beliefs. In our observation, it was a large abdominal-pelvic uterine mass in a 39-year-old nullige patient, without previous medical investigation. She had undergone a polymyomectomy without postoperative complications. Baanitse J.M, et al. reported in 2022 at the Ntamugenga hospital in Goma/Democratic Republic of Congo: the observation of a 34-year-old patient, carrying a large abdominal-pelvic mass on amenorrhea of two (02 years), thinking that the pregnancy was beyond term according to the patient. At the end of the clinical and paraclinical assessments, the diagnosis of a large dermoid cyst of the left ovary was retained. An indication for laparotomy for excision (ovarian cystectomy) was performed without postoperative complications. Boughaza et al. in Rabat, Morocco also reported a case of fibroid 20 cm in diameter in a 52-year-old perimenopausal patient without uterine preservation .

Fatima Zahra Cherrabi et al. still in Morocco had reported the case of a giant ovarian fibroid collected in the obstetrics and gynecology department of the military hospital of Rabat diagnosed by magnetic reasoning imaging. This is a 43-year-old patient, third third part, without any notable pathological history, consulted for pelvic headaches that appeared six (06) months ago and a progressive increase in abdominal volume. All of this evolved in a context of preservation of the general condition. The clinical examination found an abdominal-pelvic mass of 30 weeks of amenorrhea, firm, tender, bumpy contours and mobile. The patient underwent a laparotomy objectifying an ovary with a large mass of about 30 centimeters and having benefited from a hysterectomy with bilateral annexectomy. The treatment was exclusively a laparotomy.

We can confirm that this polymyomectomy made it possible to remedy the infertility of our patient. She had conceived her pregnancy three (03) years after the surgery. This time to conception was longer than in the series of Ekono Michel Roger Guy et al. , (18.75 months), Lebovitz et al., in the United States in 2019, as well as Ahdad Yataa et al. In 2015 in France, which found average delays of 14.3 and 9.9 months respectively [10][11]. In the other series, polymyomectomy had remedied infertility [9]-[11].

Late motherhood is the onset of pregnancy and childbirth from the age of 35 and over. Late pregnancies are considered a public health problem linked to maternal mortality because of their complications. Long considered a concern in developed countries, it is now established that late motherhood is also on the rise in developing countries, particularly in West Africa, especially in Mali . The obligation to reconcile work and family life remains a difficult equation for women in general and in particular for the most educated. . In our observation, the conception of pregnancy was spontaneous and unexpected, without fertility treatment at the age of 42, after polymyomectomy. No complications were observed.

For our patient, it was primary infertility at 41 years of age, whereas in the Ekono Michel series and primary infertility concerned 37% of patients. Buname Mosolo Patrick , had reported primary infertility in 22.21% of patients, a history of myomectomy in 5.53%, spontaneous conception in 86.6% of patients and 13.4% by ART. Our patient gave birth by caesarean section while Buname Mosolo Patrick noted 10.07% caesarean section.