Hydrometrocolpos: a Contemporary Review of the Last 5 Years

PURPOSE OF REVIEW

The goal of this review is to provide a comprehensive overview of hydrometrocolpos, covering disease etiology, pathophysiology, clinical presentation, and diagnostic and management techniques, and known outcomes.

RECENT FINDINGS

This narrative review presents the literature on hydrometrocolpos in the pediatric population from the past 5 years. We highlight the 69 reported cases of hydrometrocolpos and classify them based on type of obstruction or associated anomaly, discuss new diagnostic algorithms based on imaging, and present novel and underutilized surgical techniques for definitive management. Hydrometrocolpos, a condition characterized by retained fluid causing a distended vagina and uterus in the setting of a distal vaginal outflow obstruction, has a wide range of presentation severity based on the type of obstruction. Whether hydrometrocolpos is due to an isolated condition like imperforate hymen, a complex abnormality like cloacal malformation, or a part of a large congenital syndrome, the mainstay of treatment is decompression of the dilated vagina and surgical correction of the outflow obstruction. Imaging-based diagnostic algorithms and new treatment techniques reported in the literature, as well as longitudinal and patient-reported outcome research, can improve the lives of children affected by this condition.

Differentiating congenital ovarian cysts from other abdominal cystic lesions in female infants: A study by the Canadian Consortium for Research in Pediatric Surgery (CanCORPS)

PURPOSE

The origin of congenital abdominal cysts in the female fetus often dictates management. While most arise from the ovary and are often managed non-operatively, some are non-ovarian and are frequently removed. We analyzed a national sample of female infants with congenital abdominal cysts to elucidate prenatal and postnatal factors associated with the diagnosis of a non-ovarian cyst.

METHODS

A retrospective cohort study of female infants who were prenatally diagnosed with abdominal cysts between 2013 and 2017 at 10 Canadian pediatric surgical centres was performed. Clinical characteristics, pre- and postnatal sonographic findings, and cyst trajectories were compared between patients with proven ovarian etiology and those with cysts arising from other organs.

RESULTS

Of 185 infants with prenatally diagnosed abdominal cysts, 22 (12%) were non-ovarian, five of which had clear non-ovarian organ of origin on prenatal ultrasound. Comparison of the other 17 cysts with 163 congenital ovarian cysts showed the following factors to be associated with a non-ovarian origin: earlier gestational age at diagnosis (23.5 vs 33.5 weeks, p <0.001), smaller diameter on first prenatal ultrasound (15.8 vs. 39.7 mm, p <0.001), change in sonographic character from simple to complex (87% vs 22%, p <0.001), and postnatal sonographic characteristics of complex cyst (87% vs. 48%, p = 0.004).

CONCLUSION

Clear organ of origin, diagnosis earlier in gestation, smaller initial prenatal cyst diameter, and sonographic cyst character change differentiate congenital non-ovarian cysts from their ovarian counterparts. These characteristics may be used to guide diagnosis and management.

Antenatally detected abdominal cyst: Does cyst size and nature determine postnatal symptoms and outcome?

BACKGROUND

The outcome of antenatally detected fetal intra-abdominal cysts is highly variable and challenging to predict. Antenatal ultrasound scans may be of value in predicting postnatal outcome.

AIMS

To report antenatal and postnatal course of fetal intra-abdominal cysts identified on antenatal ultrasound and establish the value of cyst dimensions for predicting outcome.

STUDY DESIGN

Retrospective observational study.

SUBJECTS

All intra-abdominal cysts diagnosed in a single centre between 2013 and 2019.

OUTCOME MEASURES

Cyst characteristics were recorded from radiological reports and postnatal diagnosis and outcomes documented. Growth characteristics were identified to distinguish different diagnosis. The maximum antenatal diameter of all cysts was identified and the best cut-off diameter to predict whether a cyst would persist postnatally or require surgery was identified. Best cut-off values were identified using Youden index.

RESULTS

Of the 38 cysts identified on antenatal ultrasound, 24 (63%) persisted postnatally, 8 required surgery (21%) and 4 (11%) were not considered an intra-abdominal cyst postnatally. Ovarian cyst and duplication cyst may have different growth characteristics. In the prediction of cysts persisting postnatally, the area under the ROC curve (AUC) was 0.81 (95% CI, 0.66-0.95). Two cut off values were identified, 37.5 mm (50% sensitivity, specificity 100%, Youden's index 0.50) and 28.5 mm (sensitivity 65%, specificity 85%, Youden's index 0.50). In the prediction of surgery, no optimal diameter was found; AUC was 0.57 (95% CI, 0.34-0.81).

CONCLUSIONS

Maximum antenatal cyst diameter is useful for the prediction of whether a cyst will persist postnatally but not for the prediction of surgery.

A case report for a diagnostic dilemma of a giant intra-abdominal cyst with an uncertain origin

INTRODUCTION

Giant intra-abdominal cystic lesions are seldom encountered and can post a diagnostic challenge pre-operatively. These often present as increasing abdominal size and from its mass effect.

PRESENTATION OF CASE

Here, we present a case of a 58 year-old gentleman with worsening bloating and abdominal distension. A contrasted CT scan of the abdomen revealed a giant intra-abdominal cyst with no definite organ of origin. He underwent a laparotomy and excision of the giant cyst which was not found to be attached to any organ or mesentery. This resulted in resolution of his symptoms and a drastic improvement in his appetite.

DISCUSSION

It is often difficult to identify the origin of giant intra-abdominal cysts as pre-operative imaging may show it abutting multiple organs due to its size. Common intra-abdominal cysts include mesenteric, ovarian or peritoneal cysts. A precipitating history such as pancreatitis or surgical implants can suggest pseudocysts. Surgical excision alone is curative but can be difficult due to the size. Controlled intra-operative aspiration can aid in visualization and dissection.

CONCLUSION

Giant intra-abdominal cystic lesions cause significant discomfort due to its mass effect. Pre-operative investigations may not identify its cause. Surgical excision is recommended to diagnostic and therapeutic purposes.

Differences in Origin and Outcome of Intra-Abdominal Cysts in Male and Female Fetuses

OBJECTIVE

To investigate the origin and outcome in a cohort of male and female fetuses with intra-abdominal cysts, in order to provide recommendations on management and to improve prenatal counselling.

METHODS

From 2002 to 2016, intra-abdominal cysts were detected by ultrasound in 158 fetuses. Cases with an umbilical vein varix were excluded. Fetal, neonatal, and maternal characteristics were retrieved from electronic patient files.

RESULTS

In female fetuses (n = 114), intra-abdominal cysts were diagnosed at a later gestational age compared with male fetuses (n = 44) (median 32.0 vs. 21.5 weeks, p < 0.001). The maximum prenatal cyst diameter was larger in female fetuses (median 35 vs. 17 mm, p < 0.001). Associated anomalies were less frequent in females (n = 15, 13.2%) compared with males (n = 15, 34.1%). In females (n = 114), most cysts were of ovarian origin (n = 81, 71.1%). Surgery was performed in 30 (26.3%) female and 15 (34.1%) male neonates (p = 0.33). Anorectal malformations were present in 6 cases and often not recognized prenatally.

CONCLUSIONS

The differences in the origin of intra-abdominal cysts between male and female fetuses, resulting in differences in prenatal presentation and postnatal outcome should be taken into account in prenatal counseling within a multidisciplinary team. Evaluation of the fetal perianal muscular complex is indicated.