Innovation
Author Information
Shetty A*, Madhva Prasad S**, Gupta AS***.
(* Third year Resident, ** Assistant Professor, *** Professor, Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai.)
Abstract
Developmental anomalies of the Müllerian duct system represent some of the most fascinating disorders that obstetricians and gynecologists encounter. We present to you a case in which lateral approach was used to reach the collection and for excision of a non-communicating functional uterine horn.
Introduction
Müllerian duct anomalies may produce reproductive failure like abortion and preterm birth, or obstetric problems like malpresentation, retained placenta, or they may be asymptomatic. Uterus with a non-communicating functional horn is a type of Mullerian anomaly and is a rare cause of dysmenorrhea. Here, we present such a case and discuss the management strategies. Reaching and excising such a functional but a noncommunicating uterine horn can be challenging at times but excision is warranted to improve the symptomatology. Chances of occurrence of endometriosis are reduced and future fertility outcomes are likely to improve significantly.
Case Report
A 14 year old unmarried girl, who had attained menarche a year prior, presented with severe incapacitating dysmenorrhea ever since onset of menses. Cycle length was 28 days with 5 days flow. It was accompanied by severe pain, the height of which was during the menstrual flow. She was evaluated outside and found to have obstructed right functional non-communicating uterine horn and a left functional normal horn and no other medical or surgical illness.
Her general and and detailed systemic examination were within normal limits. Abdomen was soft, non-tender and no masses were felt. Per rectal examination showed midline globular tender right horn of the uterus with what appeared as a distinct palpable depression; across which a left side horn was felt. No adnexa was felt through the right or the left fornix. Impression was obstructed right functional non-communicating horn with left functional normal horn.
Ultrasonography (figure 1) showed uterus anteverted normal size and bicornuate. Left cornual endometrial echo could be traced up to cervical canal with continuity of the lumen. Right cornua was not connected to the cervical canal but it ended bluntly. Organised blood echoes were seen in this endometrial cavity.
MRI showed bicornuate uterus with right non-communicating horn, hyperintense collection in the endometrial cavity (figure 2) with right fallopian tube distended with hyperintense fluid suggestive of a hydrosalpinx. Left horn was normal. She was planned for an exploratory laparotomy with right salpingectomy and excision of right obstructed functional non-communicating horn with metroplasty. Intraoperatively, bilateral ovaries were normal. Left fallopian tube was otherwise normal but had attachment at top of the uterus. There was no uterine fundus above the insertion of the fallopian tubes. Uterine contour was normal on external examination. A faint bulge was seen over the right cornuo-fundal region on careful examination. Upon palpation, a firm globular swelling was felt in the right cornuo-fundal region; with doubtful communication to the cervical canal. However, cervix was single and appeared to be in normal communication with the left hemi-uterus. Right cornual end of the tube had a 1 cm atretic segment with doubtful connectivity to uterine cavity. Hydrosalpinx was present from cornual end just distal to the atretic segment; extending close to fimbrial end but stopping short of fimbrial end with another atretic segment. (figure 3).
Salpingectomy was done carefully ensuring that the ovarian blood supply was not compromised. Needle passed from anterior and posterior surfaces into the presumptive area of hematometra, could not reach the collection. Here, an innovative procedure suggested by Dr. S.V. Parulekar was used. Needle was passed into the hematometra through a lateral approach, between the right round ligament and the right utero-ovarian ligaments. Old collected blood about 2 cc was aspirated out. (figure 4). Diagnosis of hemi-hematometra was confirmed. With the needle as the guide a stab incision was taken and deepened (figure 5) and endometrial cavity was visualized. Lateral part of endometrium showed the tubal ostia, confirming endometrial cavity and tubal attachment. (figure 6). Gentle blunt probing was done and the extent of the horn was assessed in all directions; it was found to be around 2x2x2 centimeter. The endometrium, along with a few millimeter of myometrium was excised using cautery taking care not to excise deep into the tissue (figure 7) so as not to damage the septum between the 2 horns. Cauterization was immediately stopped when the lateral part of the wall of the functioning uterine cavity was identified. Excised tissue was sent for histopathological examination. After ensuring that no redundant endometrium was left in the right horn, small sub-centimeter pieces of gel foam were placed; and myometrial bed was approximated in consecutive layers from below upwards by taking continuous interlocking sutures with polyglactin No 1-0. By this, the functional cavity of the redundant obstructed right horn of the uterus was made non functional and was obliterated. So as to leave behind a single functional cavity of the uterus with communication to the cervix (figure 8). Postoperative course was uneventful and she menstruated subsequently and did not experience any severe excruciating dysmenorrhea..
Figure 1. Sketch drawn by sonologist to depict the pathology.
Figure 2. MRI image with blue arrow pointing to distended uterine horn and red arrow pointing to normal uterine cavity.
Figure 3. Intraoperative findings showing hydrosalpinx and slight right sided uterine bulge.
Figure 4. Laterally inserted needle aspirating blood confirming hematometra.
Figure 5. Proceeding with lateral dissection.
Figure 6. Right sided functional horn excision and coring of endometrium. Blue arrow pointing out to coagulated myometrium, green arrow is pointing out the left horn bulging through the septum between the two horns.
Figure 7. Cavity sutured.
Figure 8. Final view after suturing of serosa.
Discussion
Surgical procedure designates the correct diagnosis of type of Mullerian anomaly. In our case, the MRI was suggestive of bicornuate uterus with a non-communicating horn. However, intraoperative features, which is the gold standard, showed it to be a septate uterus with a partial septum running from top of the uterus to the right wall, dividing the uterine cavity unequally resulting in non-communication with the cervical canal on the right side. The functional endometrium thus trapped within the smaller cavity caused the severe dysmenorrhea and made her seek medical help soon after menarche.
Terminology and classification of Mullerian anomalies continues to be imperfect, and our patient would probably not fit into any of the classes in the American Fertility Society classification, the VCUAM classification or the Clinical Embryological classification. It would fit into a rather broad U6 (Unclassified Malformations) in the ESHRE classification.[1] The EAC classification is one which may help in correct scientific communication of this malformation, the main advantage being that functionality is also taken into account;[2] and not just the morphological features, as in most other classifications. This patient fits into an unclassified Mullerian anomaly.
When there is no communication between the functional horn and its main functional endometrial cavity or the cervix, symptomatology of severe dysmenorrhea, hematometra and hematosalpinx is expected.[3]
In our case, the symptomatology was seen and hematometra was observed; but hematosalpinx was not observed. This is due to atretic segments of fallopian tube in the cornual end. Probably due to this, she presented at a much earlier time than otherwise expected. Endometriosis was also not seen, though it is expected in patients with non-communicating functional horns with canalized fallopian tubes due to retrograde menstruation.
Many different methods of imaging can be used for confirmation of type of Mullerian abnormality. Ultrasonography is a well-accepted modality; however, 3 dimensional ultrasonography is the best and performs well in comparison to gold standard MRI.[4] As the collection was small we could not reach it anteriorly or from the posterior or superior aspect. However as the myometrium is thinnest in the lateral wall at the cornua the lateral approach worked by a lateral thought process. Though not entirely similar, when other techniques are not feasible, a lateral approach can be considered in surgery of the uterus, as described for myomectomy procedures.[5]
Excision of the horn and coring out of the endometrium was done. Our method also ensured that the resulting lateral wall of the functional horn did not weaken as the majority of the myometrium was retained after coring of the endometrium and closed so as to strengthen the inner septum. As described, this was achieved by open technique. If surgical expertise is available, laparoscopic/ hysteroscopic excision can be considered. But whether the outcomes are better, is not yet clear.[6,7] We present this case so that readers remember this lateral approach when faced with dilemma during surgery and restrict excision to bare minimum.
Acknowledgement
Dr. S.V. Parulekar, Professor and Head for innovating the unique lateral approach to reach the collection inside the hemiuterus of a septate uterus .
References
- Grimbizis GF, Campo R. Clinical approach for the classification of congenital uterine malformations. Gynecol Surg. 2012; 9(2):119–29.
- Parulekar SV. EAC Classification Of Congenital Malformations Of The Female Genital Tract. JPGO 2015;2(4). Available from: http://www.jpgo.org/2015/04/eac-classification-of-congenital.html
- Woźniakowska E, Stępniak A, Czuczwar P, Milart P, Paszkowski T. Secondary dysmenorrhea due to a, non-communicating functional uterine horn. Ginekol Pol. 2017;88(7):404–5.
- Ergenoglu AM, Sahin Ç, Şimşek D, Akdemir A, Yeniel AÖ, Yerli H et al. Comparison of three-dimensional ultrasound and magnetic resonance imaging diagnosis in surgically proven Müllerian duct anomaly cases. Eur J Obstet Gynecol Reprod Biol. 2016 Feb;197:22-6.
- Parulekar SV. Myomectomy: Lateral Extraperitoneal Approach. JPGO 2014; 1(2). Available from: http://www.jpgo.org/2014/02/myomectomy-lateral-extraperitoneal.html
- Dwivedi R, Perera K, Eedarapalli P. Non-Communicating inactive rudimentary horn of the uterus presenting with dysmenorrhoea—a case report of successful laparoscopic excision. Open J Obstet Gynecol [Internet]. 2011;1:213–6. Available from: http://www.scirp.org/journal/ojog/
- Akdemir A, Ergenoglu AM, Yeniel AÖ, Sendag F, Karadadaş N. Coring-type laparoscopic resection of a cavitated non-communicating horn under hysteroscopic assistance. J Obstet Gynaecol Res. 2014;40(7):1950–4.
Shetty A, Madhva Prasad S, Gupta AS. Lateral Approach To Hemihematometra. JPGO 2017. Volume 4 No.10. Available from: http://www.jpgo.org/2017/10/lateral-approach-to-hemihematometra.html