Congenital Obstructive Müllerian Anomaly: The Pitfalls of a Magnetic Resonance Imaging-Based Diagnosis and the Importance of Intraoperative Biopsy

MR Diffusion Kurtosis Imaging (DKI) of the Normal Human Uterus in Vivo During the Menstrual Cycle

BACKGROUND

The uterus undergoes dynamic changes throughout the menstrual cycle. Diffusion kurtosis imaging (DKI) is based on the non-Gaussian distribution of water molecules and can perhaps represent the changes of uterine microstructure.

PURPOSE

To investigate the temporal changes in DKI-parameters of the normal uterine corpus and cervix during the menstrual cycle.

STUDY TYPE

Prospective.

POPULATION

21 healthy female volunteers (26.64 ± 4.72 years) with regular menstrual cycles (28 ± 7 days).

FIELD STRENGTH/SEQUENCE

Readout segmentation of long variable echo-trains (RESOLVE)-based DKI and fast spin-echo T2-weighted sequences at 3.0T.

ASSESSMENT

Each volunteer was scanned during the menstrual phase, ovulatory phase, and luteal phase. Regions of interest (ROI) were manually delineated in the endometrium, junctional zone, and myometrium of the uterine body, and in the mucosal layer, fibrous stroma layer, and loose stroma layer of the cervix. The mean Kapp (diffusion kurtosis coefficient), Dapp (diffusion coefficient), and ADC (apparent diffusion coefficient) values were measured in the ROI.

STATISTICAL TESTS

ANOVA with Bonferroni or Tamhane correction. Intraclass correlation coefficient (ICC) for assessing agreement. P < 0.05 was considered statistically significant.

RESULTS

During the menstrual cycle, the highest Kapp (0.848 ± 0.184) and lowest Dapp (1.263 ± 0.283 *10-3 mm2/sec) values were found in the endometrium during the menstrual phase. The Dapp values for the myometrium were significantly higher than those of the endometrium and the junctional zone in every phase. Meanwhile, the Dapp values for the three zonal structures of the cervix during ovulation were significantly higher than those during the luteal phase. However, there was no significant difference in the ADC values of the loose stroma between ovulation and the luteal phase (P = 0.568). The reproducibility of DKI parameters was good (ICC, 0.857-0.944).

DATA CONCLUSION

DKI can show dynamic changes of the normal uterus during the menstrual cycle.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 2.

A New Case of Herlyn–Werner–Wunderlich Syndrome: Uterine Didelphys with Unilateral Cervical Dysgenesis, Vaginal Agenesis, Cervical Distal Ureteral Remnant Fistula, Ureterocele, and Renal Agenesis in a Patient with Contralateral Multicystic Dysplastic Kidney

The aim of this study was to present a new case of congenital Herlyn–Werner–Wunderlich syndrome, a rare anomaly of the female reproductive tract, and review the related literature. A 12-year-old girl presented with severe dysmenorrhea since menarche and magnetic resonance imaging showing a bicornuate uterus, double cervix, right hematometra, and hematosalpinx with ipsilateral renal agenesis, accompanied by a remnant distal ureter with hydroureter. A diagnostic cystoscopy and a reduced-port robot-assisted laparoscopy with chromopertubation were performed in order to identify the anomaly. Uterine didelphys and right cervical dysgenesis with ipsilateral vaginal agenesis, cervical distal ureteral remnant fistula, ureterocele, and renal agenesis were diagnosed on the basis of histopathologic findings, and she subsequently underwent a robotic unilateral right total hysterectomy with salpingectomy. This case report reinforces the importance of the intraoperative biopsy for an accurate diagnosis, despite magnetic resonance imaging being considered the gold-standard diagnostic tool.