Introduction
Uterine smooth muscle tumors of uncertain malignant potential (STUMPs) represent a rare and diagnostically challenging subset of uterine neoplasms that lie in the gray zone between benign leiomyomas and malignant leiomyosarcomas. First defined by the World Health Organization in 2003, STUMPs lack definitive histopathologic criteria for benignity or malignancy, making both diagnosis and management inherently complex [1]. Clinically, these tumors often mimic leiomyomas, presenting with abnormal uterine bleeding, pelvic pain, or mass effect, and are frequently diagnosed only after surgical excision.
The increasing trend toward delayed childbearing has heightened the importance of fertility-preserving strategies in gynecologic oncology. Myomectomy remains the standard surgical option for women desiring uterine conservation, particularly in symptomatic fibroids. However, when histopathology reveals STUMP, clinicians face a dilemma: while hysterectomy is traditionally recommended due to uncertain malignant potential, it may not be acceptable in young nulliparous women seeking future fertility.
Recent literature suggests that fertility-sparing management with myomectomy may be a reasonable alternative in carefully selected patients, with reported pregnancy rates approaching 38-40% and no clear increase in malignant transformation compared to hysterectomy. Nonetheless, recurrence rates remain variable, and long-term oncologic safety is not fully established.
Advances in minimally invasive surgery, particularly robotic-assisted myomectomy, have further refined surgical outcomes by improving precision, reducing blood loss, and enhancing recovery. Techniques such as bilateral uterine artery ligation or occlusion during myomectomy have been explored to minimize intraoperative hemorrhage, though their impact on ovarian reserve and fertility outcomes remains an area of ongoing research.
Another critical issue in STUMP management is specimen retrieval. The use of morcellation, especially power morcellation, has been controversial due to the potential risk of disseminating occult malignancy. Contained extraction techniques and careful intraoperative assessment are therefore essential when malignancy cannot be excluded preoperatively.
In this context, we present a case of a young nulliparous woman who underwent robotic myomectomy with bilateral uterine artery ligation for a presumed leiomyoma, subsequently diagnosed as STUMP. This case highlights the challenges of preoperative diagnosis, intraoperative decision-making, specimen retrieval, and balancing fertility preservation against oncologic uncertainty. This is a single case study, and further case studies are required to enhance the importance of fertility-sparing myomectomy in cases of doubtful borderline malignancies. This work was previously presented as an oral poster at the All Kerala Congress of Obstetricians and Gynecology 2026 on January 21, 2026.
