A Review of Mullerian Anomalies and Their Urologic Associations

Keep your attention closer to the ureters: Ureterolysis in deep endometriosis surgery

Endometriosis surgery involving the ureter poses significant challenges requiring meticulous surgical techniques and vigilant postoperative care. This chapter addresses key aspects of ureterolysis techniques, intraoperative management of ureteral injuries, and postoperative care in the context of endometriosis surgery. Ureterolysis methods aim to isolate and mobilize the ureter while preserving its vascularity. Cold instruments and careful dissection are recommended to prevent thermal injury during surgery. Intraoperative tools such as indocyanine green (ICG) show promise in assessing for vascular compromise. Over half of ureteral injuries are detected postoperatively, necessitating a high index of suspicion. Optimal postoperative care in the case of ureteral injury involves Foley catheterization for decompression, ureteral stenting, and meticulous follow-ups to monitor healing and renal function. While advances have been made in surgical techniques and diagnostic tools, gaps persist in preoperative imaging optimization and predictive models for identifying at-risk patients. This chapter aims to bridge existing knowledge gaps, optimize surgical practices, and enhance the overall care and outcomes of patients undergoing endometriosis surgery involving the ureter.

Congenital interruption between the ampulla and fimbria of the fallopian tube: case report

We reported 5 patients with unilateral or bilateral tubal discontinuity between the ampulla and fimbria, occasionally detected through laparoscopy combined with hysteroscopy at the Reproductive Hospital Affiliated with Shandong University from 2017 to 2023. Three cases were observed to have this malformation on the left fallopian tube, 1 case on the right side, and 1 case bilaterally. None of these cases were combined with urological malformations. After surgery, there was 1 instance of postoperative delivery, 1 ongoing pregnancy, and 3 not yet conceived. The congenital ampulla and fimbria interruption of the fallopian tube may be independent of other significant deformities of reproductive or renal tracts. However, it can lead to hydrosalpinx and primary or secondary infertility. Surgical management options, such as salpingostomy, salpingectomy, and tubal ligation, have shown the potential to improve pregnancy outcomes.

Case report: Ureteric bud intestinal-type adenocarcinoma involving the cervix was misdiagnosed as a large cervical fibroid

Background

Malignant tumors of the ureteric bud are not common, and cervical involvement is even rarer. So far, there have been no such cases in the literature.

Case summary

A 50-year-old woman developed intermittent light bleeding in the past 7 months and lower abdominal pain in the past 2 months. The human papillomavirus 16 (HPV) DNA, P16 chemical staining, thinPrep cytology test (TCT), and cervical and cervical canal tissue biopsy were all negative. Pelvic color Doppler ultrasound exhibited incomplete mediastinal uterus and heterogeneous echo from the cervical canal to the posterior wall of the cervix. Pelvic contrast-enhanced CT showed left cervical mass, left retroperitoneal mass, absence of the left kidney, and mediastinal uterus. An increase in human epididymal protein 4 (HE4) (133.6 pmol/L) was detected, while other tumor markers were at normal levels. Based on these examination results, a diagnosis of "cervical fibroids, left retroperitoneal mass, incomplete mediastinal uterus, left kidney deficiency"[SIC] was conducted, and expanded hysterectomy, right adnexectomy, and left retroperitoneal mass resection were performed. Through intraoperative rapid pathological diagnosis, postoperative pathological diagnosis combined with the re-evaluation of laboratory, and imaging and intraoperative examination results, the patient was diagnosed with ureteric bud intestinal-type adenocarcinoma involving the cervix. The patient has been tracked and followed up for approximately 11 months. She underwent six courses of chemotherapy. At present, the medication has been discontinued for 4 months, and there is no recurrence, metastasis, or deterioration of the tumor.

Conclusion

For large masses of the cervix, it is feasible for the operation to be performed, improving the prognosis. There were a few limitations. A preoperative aspiration biopsy of masses was not performed to differentiate benign from malignant. Preoperative urography was not performed to clarify the function of the malformed urinary system structure. Partial cystectomy should be performed simultaneously with the resection of the ureteric bud for intestinal-type adenocarcinoma. In this case, a partial cystectomy was not performed, which can only be compensated with postoperative chemotherapy. Moreover, this patient did not undergo genetic screening, and it is currently unclear whether there are any genetic mutations associated with ureteric bud intestinal adenocarcinoma.

Endometrial Cancer in a Patient With Didelphys Uterus and a History of Renal Cancer: A Case Report and Literature Review

Müllerian duct anomalies (MDAs) concurrent with endometrial cancer are exceptionally rare, with only a few documented cases. Here, we present a case of endometrial cancer in both horns of a didelphys uterus in a 54-year-old woman with a history of renal cancer, who underwent left radical nephrectomy and left salpingo-oophorectomy. The patient sought medical evaluation due to postmenopausal vaginal bleeding. Hysteroscopy with dilation and curettage revealed the presence of two cervixes and two endometrial cavities, with pathology results indicating endometrioid adenocarcinoma (G1). Preoperative MRI staging confirmed the diagnosis of a double cervix and uterus. Subsequently, an open abdominal hysterectomy and a right salpingo-oophorectomy were performed, revealing a didelphys uterus (International Federation of Gynaecology and Obstetrics 2018, stage IA). This manuscript aims to explore the potential correlation between renal and endometrial malignancies in the presence of MDAs.

Cervically Embedded Fragment of an Intrauterine Device in a Patient with a Bicornuate Uterus: A Case Report and Review of Current Management Strategies

Intrauterine devices (IUDs) have become one of the most frequently used forms of long-acting reversible contraception (LARC) in women of childbearing age. While complications are generally considered to be minimal, they can occur during the insertion, during use, or upon removal. Uterine anomalies, such as a bicornuate uterus, can increase the risk of complications during all stages. Here, we describe a case of a patient with a bicornuate uterus who had a levonorgestrel IUD in place for five years before she experienced a dislodging of the IUD, fragmentation upon attempted removal, and ultimately required a hysteroscopy to remove an embedded fragment from the endocervical canal. Due to the limited reporting on fragmented IUDs, further studies will be required to assess the optimal management. While symptomatic patients should have the fragment removed, asymptomatic patients should have their individual history and desire for future pregnancy weighed against the risk and benefits of treatment.

Cervix Surgical uterine evacuation in patients with two cervices: a case series

OBJECTIVES

To describe the clinical circumstances, surgical approach, intraoperative challenges, and outcomes of patients with two cervices undergoing uterine evacuation for spontaneous, incomplete, or induced abortion at our institution.

STUDY DESIGN

We used diagnostic and procedure codes related to uterine anomalies and uterine evacuation to identify patients with cervical duplication who underwent uterine evacuation at Penn Medicine from January 2008 to December 2020.

RESULTS

We identified fifteen patients with cervical duplication in whom we performed uterine evacuations during nineteen pregnancies. We describe in detail each patient's first pregnancy with uterine evacuation at our institution, of which providers performed eleven in the first trimester and four in the second trimester. Ten patients had a known diagnosis of cervical duplication prior to pregnancy. Five patients did not have a diagnosis of cervical duplication prior to pregnancy and providers newly made this diagnosis intraoperatively either at our institution or referring clinics. Providers at outside institutions referred three patients to our institution for incomplete procedures. At our institution, one patient had a procedure notable for a major complication. Eight other cases were notable for surgical challenges including difficulty placing osmotic dilators, difficulty identifying the correct cervix for local anesthesia, and contralateral cervical and uterine horn instrumentation.

CONCLUSIONS

This case series suggests surgical abortion in patients with two cervices is rare, but generally safe. The majority of patients did not have major complications, despite presenting a variety of unique procedural challenges. Surgical providers were sometimes the first to make the diagnosis of a second cervix.

Diagnosis and Therapy of Female Genital Malformations (Part 2). Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/052, May 2019)

Objectives Female genital malformations may be present in the form of individual entities, they may involve neighboring organs or they may occur in the context of complex syndromes. Given the anatomical structures of the vulva, vagina, uterus and uterine appendages, the clinical picture of malformations varies greatly. Methods This S2k-guideline was developed by representative members from different medical specialties and professions as part of the guidelines program of the DGGG, SGGG and OEGGG. The recommendations and statements were developed and voted on using a structured consensus process with neutral moderation. Recommendations This guideline is the first comprehensive summary of female genital malformations from infancy to adulthood which covers clinical examinations, diagnostic workups and treatment options. Additional chapters have been included on complex urogenital malformations, vascular malformations, psychosomatic care, and tumor risk.