Laparoscopic excision of a noncommunicating rudimentary uterine horn

Unicornuate uterus with a rudimentary non-communicating cavitary horn in association with VACTERL association: a rare case report

Mullerian anomalies are malformations that affect the embryological development of paramesonephric ducts and are associated with multiple urogenital defects due to shared embryology, including VACTERL association, which coexists in about one-third of these patients. We report a rare case of a unicornuate noncommunicating horn uterus with a rudimentary second horn in a known case of VACTERL association in a 16-year-old girl.

Unicornuate uterus with a rudimentary non-communicating cavitary horn in association with VACTERL association: case report

Background

The unicornuate uterus is caused by abnormal or failed development of one Müllerian duct. Unicornuate uteri with functioning non-communicating rudimentary horns are susceptible to many gynaecologic and obstetric complications such as hematometra, endometriosis and ectopic pregnancy and thus surgical resection is usually recommended..

Case presentation

We report a rare case of a unicornuate right uterus with rudimentary non-communicating (functional) cavitary left horn (class U4a) in a 17-year-old girl who was diagnosed with VACTERL association. She was presented to our centre with 3 years history of secondary sever dysmenorrhea. Pelvic magnetic resonance imaging revealed a normal uterus on the right side, a 7 × 8 cm left endometrioma, a tortuous dilated fluid-filled structure in the left hemipelvis, mostly represented left-sided hematosalpinx, and a well-defined lesion with thick enhancing wall in the left hemipelvis measuring 6.7 × 5.7 × 5.6 cm with a similar enhancement to the uterus in the right. She underwent laparotomy that showed a right unicornuate uterus with a normal cervix and a rudimentary non-communicating distended left horn. In addition, there was a left endometrioma and left hematosalpinx. Resection of the left communicating horn, left salpingectomy and left ovarian cystectomy were performed. The right tube and both ovaries were preserved. At 9-months follow up, the patient had a regular period and the pain subsided completely.

Conclusion

We report yet the second case of VACTERL association and unicornuate uterus with non-communicating functional rudimentary horn, in hope of expanding the knowledge of a rare occurrence. This case also highlights the importance of considering the diagnosis of Müllerian duct anomalies in patients with a history of other anomalies, and/or history of early-age secondary dysmenorrhea.

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.

Obstructive mullerian anomalies and modern laparoscopic management

STUDY OBJECTIVE

Congenital uterine anomalies are common, although the majority are asymptomatic. When an obstructed system exists, women may present with abdominal pain, or dysmenorrhea. Removal of the obstructed horn may be required in the symptomatic patient. In the past, surgical treatment necessitated a laparotomy.

DESIGN

After preoperative diagnosis and planning using magnetic resonance imaging, laparoscopic removal of the obstructed uterine horn and tube was performed. Morcellation of tissue was used to permit removal through a 15mm port.

SETTING

A central London tertiary referral teaching hospital.

PARTICIPANTS

15 women aged between 13 and 41.

INTERVENTIONS

Between 1999 and 2005, all women underwent laparoscopic removal of the obstructed uterine horn and tube.

MAIN OUTCOME MEASURES

Recovery, hospital stay, length of operation.

RESULTS

All women recovered well, with an operation time of 80 to 300 minutes and an average hospital stay of 5 days.

CONCLUSIONS

A laparoscopic approach is a safe and appropriate technique for the removal of an obstructed uterine horn.

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.

Resection of a non-communicating uterine horn with use of the harmonic scalpel

BACKGROUND

Type IIA1b anomalies of the Mullerian system are rare. Traditionally, the method of treatment for such anomalies has been laparotomy.

CASE

We discuss a case of this specific anomaly treated by resecting the non-communicating horn with the harmonic scalpel (Ethicon EndoSurgery, Cincinnati, Ohio) by first confirming a lack of communication with hysteroscopy, followed by chromotubation to demonstrate unilateral spill from the right side without leak from the area of dissection.

CONCLUSION

Minimally invasive techniques are an excellent alternative to laparotomy for correction of problems related to Mullerian anomalies.

Finger-assisted laparoscopy to remove a noncommunicating uterine horn

A 21-year-old-woman had a double uterus with noncommunicating right uterine horn and communicating left uterine horn. The pelvic cavity showed evidence of endometriosis and adhesions from previous laparotomy. A finger was inserted under laparoscopic observation without gas leakage through an iris access port in the lower abdominal wall, which required only a small incision. An index finger was adequate to separate and manipulate inflamed tissue and to assess a connection of horns.

Laparoscopic management of a unicornuate uterus with two cavitated, non-communicating rudimentary horns: case report

An 18 year old nulligravid woman presented with severe dysmenorrhoea secondary to stage IV (revised American Fertility Society) endometriosis, right haematosalpinx, right endometrioma, unicornuate uterus and two cavitated, non-communicating rudimentary uterine horns. To our knowledge, this is the first reported case of a unicornuate uterus accompanied by two rudimentary horns. Operative video-laparoscopy proved a successful approach for treating this previously unreported variant of congenital Müllerian anomaly. A review of the world literature confirms the uniqueness of this case while demonstrating laparoscopy to be a viable alternative to laparotomy for management of congenital Müllerian anomalies. The case presented may help to elucidate Müllerian duct embryology further.