Laparoscopic surgery of unicornuate uterus with rudimentary uterine horn

Reproductive Outcome of the Patients with Uterus Unicornis: Five Year Experience in a Tertiary Center

Aim

The aim is to evaluate the pregnancy outcomes of patients with uterus unicornis for 5-year experience in a tertiary center.

Material and Method

Twenty patients with uterus unicornis who were diagnosed with hysterosalpingography and/or 3D TVUSG between 2017 and 2021 and then confirmed with laparoscopy and simultaneous hysteroscopy were recruited into this retrospective study. The reproductive outcome and obstetric complications of the patients were followed up for two years postoperative period.

Results

Overall 20 patients who fulfilled the inclusion criterion were recruited for the study. The mean age was 28.65±5.03 years. Thirteen patients (65%) had primary infertility while the remaining seven had secondary infertility with two of them having a previous ectopic pregnancy. Rudimentary communicating uterine horn was observed in 7 (35%) of the patients. The horns were excised during laparoscopy. Overall, 14 (70%) pregnancies were achieved during the 2 years follow-up period. Twelve (85.7%) patients had a live birth (71.4% term delivery, 21.4% preterm delivery), and two (15.3%) had a first-trimester spontaneous abortion. Six (50%) of 12 patients who had a live birth received tocolytics for preterm labor.

Conclusion

Unicorn uterus is a rare anomaly diagnosed mostly during infertility work-up and might be related to the poor obstetric outcome, but early diagnosis is important for successful pregnancy results for preterm delivery especially in the secondary infertile group. In addition, rudimentary horn excision is recommended due to the high risk of obstetric complications.

The role of laparoscopy in paediatric and adolescent gynaecology

Paediatric and adolescent gynaecology is a narrow field of medicine dealing with the diagnosis of and treatment of gynaecological diseases from the neonatal period to sexual maturity. The current trend in surgical gynaecology in the paediatric population is to minimise the degree of invasiveness of diagnostic and therapeutic procedures. This contributes to reducing the number of complications and the risk of infertility. Laparoscopic procedures are a challenge for paediatric surgeons and gynaecologists, not only because of the age of treated patients, and anatomical and physiological differences between different age groups but also because of the complexity of the pathology, the differentiation of cancer tumours, and the presence of congenital developmental defects.

A Stepwise Approach to Laparoscopic Excision of a Noncommunicating Rudimentary Horn

STUDY OBJECTIVE

To demonstrate our approach to laparoscopic excision of a noncommunicating rudimentary horn (AmericanSociety for Reproductive Medicine classification II(b), European Society of Human Reproduction and Embryology/European Society of Gynaecological Endoscop classification class U4a).

DESIGN

Technical video (Canadian Task Force classification level III).

SETTING

University Hospital.

PATIENT

A 25-year-old women with a left-sided pelvic mass.

INTERVENTION

Laparoscopic excision of noncommunicating rudimentary horn with hysteroscopy and cystoscopy. Institutional Review Board/Ethics Committee ruled that approval was not required for this study.

MEASUREMENTS AND MAIN RESULTS

Noncommunicating rudimentary horns are present in 20% to 25% of women with a unicornuate uterus [1]. Noncommunicating rudimentary horns may be associated with dysmenorrhea, pelvic pain, subfertility, and poor obstetric outcomes. Laparoscopic excision of rudimentary horns can be challenging and complex. Factors to consider in relation to the rudimentary horn are attachment to the uterus, presence and course of the ureter, and vascular supply. In this video we demonstrate our approach to laparoscopic excision of a rudimentary horn including preoperative imaging to plan surgical care. A 25-year-old women presented with pelvic pain and underwent a laparotomy for a left-sided pelvic mass. Intraoperatively, a rudimentary horn was suspected, and she was started on a gonadotropin-releasing hormone analogue pending diagnostic imaging and definitive surgery. Computed tomography demonstrated an absent left kidney and ureter. Intraoperatively, we began with a cystoscopy to identify and confirm an efflux from ureteral openings. A real-time hysteroscopy was performed to identify the unicornuate uterus from the rudimentary horn and to exclude vaginal or cervical anomalies. Through hysteroscopic transillumination the plane of dissection was identified between the rudimentary horn and uterus [2,3]. This technique is especially useful when the rudimentary horn is densely fused to the unicornuate uterus. Retroperitoneal dissection was performed ipsilateral to the rudimentary horn. A lateral approach was used to coagulate the uterine artery at its origin. The bladder was reflected from the horn to allow excision. A Thunderbeat device (Olympus Medical Systems, Tokyo, Japan) was used to excise the rudimentary horn, keeping very close to the specimen to ensure no penetration of the unicornuate uterus. Hemostasis was achieved, and no additional sutures were required. The specimen was removed using in-bag morcellation.

CONCLUSION

A stepwise hysteroscopic and laparoscopic approach can be used to safely resect a rudimentary horn as demonstrated by this case.

Torsion of a rudimentary uterine horn at 22 weeks of gestation

Rudimentary uterine horn is an uncommon abnormality of the female reproductive tract. Torsion of rudimentary uterine horn in pregnancy is even rarer. A case of successful excision of distorted rudimentary uterine horn in the second trimester, which caused severe abdominal pain, is described. A congenital absence of the right kidney was discovered simultaneously. The pregnancy continued uneventfully until term delivery.

Laparoscopic excision of a rudimentary uterine horn in a child

Unicornuate uterus with a rudimentary horn is the rarest congenital anomaly of the female genital system. It can result in a variety of gynecologic and obstetric complications. This case report is an acute presentation of a cavitated, noncommunicating, rudimentary horn in a premenarcheal girl. Successful laparoscopic excision was performed. The full extent of the anomaly was diagnosed by a combination of operative findings and postoperative magnetic resonance imaging.

Diagnosis and laparoscopic management of a rudimentary uterine horn in a teenage girl, presenting with haematometra and severe endometriosis: our experience and review of literature

A unicornuate uterus is a rare congenital malformation of the female genital tract, which appears in about 1/1000 women and is characterized by significant anatomic variability. In the most common type, a noncommunicating rudimentary horn coexists with the unicornuate uterus. The diagnosis of this anomaly is usually delayed, as it remains asymptomatic until adolescence and its initial symptoms are atypical. As a result, it is often diagnosed after the appearance of severe complications, such as haematometra, endometriosis, infertility and ectopic pregnancy. We report a case of a teenage girl presenting with dysmenorrhoea, endometriosis and haematometra secondary to a noncommunicating rudimentary horn. The diagnosis of the anomaly was based on magnetic resonance imaging (MRI) and laparoscopy. The excision of the symptomatic rudimentary horn and the ipsilateral fallopian tube was also performed laparoscopically. A review of the literature follows, focusing mainly on the diagnosis and laparoscopic management of a unicornuate uterus and its complications in adolescence. Laparoscopy is an accurate diagnostic tool, which also carries significant advantages in effective surgical management of congenital uterine anomalies, especially in young women.

Laparoscopic management of a cavitated noncommunicating rudimentary uterine horn of a unicornuate uterus: a case report

Introduction

A unicornuate uterus with a rudimentary horn is the most uncommon uterine anomaly of the female genital tract. It has an estimated frequency of one in 100,000 among the fertile female population. This anomaly results from the abnormal maturation of one Müllerian duct with the normal development of the contralateral one.

Case presentation

We report here the case of a 14-year-old Caucasian girl who came to our hospital with intense dysmenorrhea. Imaging techniques revealed a unicornuate uterus with a rudimentary horn and a large hematosalpinx. We performed a laparoscopic removal of this uterine anomaly without any complication in the postoperative period.

Conclusion

In our case report, we demonstrate that laparoscopy is the best approach for the treatment of IIb Müllerian abnormalities. Laparoscopy resulted in anatomical and reproductive results equivalent to those offered by a laparotomic approach, but with the additional advantages of minimally invasive surgery, such as better cosmetic results and postoperative period, which are essential for very young patients.

Case of iatrogenic dysmenorrhea in non-communicating rudimentary uterine horn and its laparoscopic resection

Abstract A case of non-communicating rudimentary uterine horn is presented and is a characteristic example of the way that surgical treatment can exacerbate dysmenorrhea by blocking retrograde menstruation. There is always some risk of missing the true diagnosis in cases of uterine abnormalities, even by direct inspection, but intraoperative laparoscopic ultrasonography can be an invaluable tool in defining anatomy. As laparoscopic resection has become the standard procedure for the treatment of unicornuate uterus, laparoscopic ultrasonography can be a useful tool for providing anatomical information to the operating surgeon about the patient.

The Presentation and Early Diagnosis of the Rudimentary Uterine Horn

OBJECTIVE

The key to successful management of the rudimentary uterine horn is early detection. This review of the literature seeks to illustrate important aspects of diagnosis and management of this anomaly.

DATA SOURCES

An English language MEDLINE search from 1966 to 2003 was performed, using the search terms "rudimentary uterine horn," "accessory horn," "uterus bicornis unicollis," "hematometra," "unicornuate or bicornuate uterus," and "mullerian anomaly." References from previously published sources were also obtained.

METHODS OF STUDY SELECTION

One hundred thirty letters, case reports, case series, and review articles featuring rudimentary uterine horn were found. Reports before 1966 were excluded because outcomes before the advent of modern diagnostic techniques were not relevant to this study.

TABULATION, INTEGRATION, AND RESULTS

Three hundred sixty-six rudimentary horn presentations (210 gynecologic and 156 obstetric) were found. Noncommunicating horns accounted for 92% of cases (95% confidence interval [CI] 88-95%, P < .001), and renal anomaly was found in 36% (95% CI 29-44%). Contrary to the American Fertility Society classification of uterine anomalies, rudimentary horns may occur without a corresponding unicornuate uterus. The mean age of presentation was similar for gynecologic and obstetric presentations (23 and 26 years, 95% CIs 21.2-24.6 and 124.9-27.3 years, respectively). Presentation in the third decade of life or later occurred in 78% of patients (95% CI 70-84%, P < .001). Sensitivity of ultrasound examination for diagnosis was 26% (95% CI 18-36%). Diagnosis before clinical symptoms occurred in 14% (95% CI 7-23%).

CONCLUSION

Many functional noncommunicating horns present during or after the third decade of life with acute obstetric uterine rupture. Surgical removal before pregnancy is recommended. Rates of prerupture diagnosis remain disappointingly low.

Laparoscopic removal of the cavitated noncommunicating rudimentary uterine horn: surgical aspects in 10 cases

OBJECTIVE

To report our experience on laparoscopic resection of the cavitated noncommunicating rudimentary horn in 10 patients with unicornuate uterus.

DESIGN

Descriptive study.

SETTING

A tertiary referral center for the treatment of female genital malformations.

PATIENT(S)

Ten consecutive patients operated between 1994 and 2002.

INTERVENTION(S)

Laparoscopic removal of the rudimentary uterine horn.

MAIN OUTCOME MEASURE(S)

Operating time, intraoperative and postoperative complications, relief of symptoms at a 6-month follow-up.

RESULT(S)

Median operating time was 65 minutes (range 40-92 minutes) with neither intraoperative nor postoperative complications. All patients were discharged within 72 hours from the procedure. Clinical follow-up during 6 months showed a marked improvement of symptoms.

CONCLUSION(S)

Laparoscopy proves to be an effective surgical approach for the removal of the cavitated noncommunicating rudimentary horn in patients with unicornuate uterus.

Laparoscopic Excision of Symmetric Uterine Remnants in a Patient with Mayer-Rokitansky-Ku¨ster-Hauser Syndrome

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is an infrequent developmental defect characterized by congenital absence of the vagina and uterus. Various anomalies of the müllerian system have been operated on by laparoscopy. We performed operative laparoscopy to remove symmetric uterine remnants and right ovarian endometrioma in a woman with MRKH syndrome who suffered from intractable lower abdominal pain. Both anomalous structures, which had true uterine vessels, were located on their respective pelvic sidewalls close to the ureters. We suggest that operative laparoscopy can be performed safely to treat these patients, but careful identification and dissection of the main blood supply, if necessary, are of substantial importance in order to avoid ureteral injury.