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Laparoscopic resection of a noncommunicating rudimentary uterine horn
August 1997, Vol. 4, No. 4
TheJournal of the American Associationof Gynecologic Laparoscopists
Laparoscopic Resection of a Noncommunicating Rudimentary Uterine Horn Konstantinos Giatras, M.D., Frederick L. Licciardi, M.D., and Jamie A. Grifo, M.D., Ph.D. Abstract Two women had infertility due to a symptomatic unicornuate uterus associated with rudimentary contralateral horn. Both carried successful pregnancies after laparoscopic resection of the horns. (J Am AssocGynecol Laparosc 4(4):491-493, 1997)
Unicornuate uterus with rudimentary horn is a rare mullerian abnormality that results from arrest in the development of one of the mullerian ducts and inappropriate fusion with the contralateral side. 1 Both unicornuate uterus and rudimentary horn containing an endometrial cavity are associated with various reproductive difficulties. 2 This mullerian abnormality can cause variable complications, such as hematometra and endometriosis, leading to acute abdominal pain, infertility, and obstetric complications. These include miscarriage, preterm delivery, or rupture of the uterus, especially when the pregnancy occurs in the rudimentary horn. Resection of the rudimentary horn in symptomatic, infertile women is indicated.
gynecologic history was marked by regular cycles with aggravated dysmenorrhea in the previous 2 years. She took oral contraceptives for 5 years, which she ceased because she wanted to conceive. Gynecologic examination revealed complete maturation of secondary sex characteristics with normal vulva, labia majora and minora, and clitoris. Speculum examination showed a single normal cervix and normal vagina. Bimanual examination revealed a deviated uterus to the left with perception of a right small mass. On hysterosalpingogram, a unicornuate uterus was deviated to the left side, with normal spill of dye from that tube. No communication with the rudimentary horn was noted. Vaginal ultrasound showed a uterus with functioning endometrium with a small right adnexal mass. Both kidneys and ureters were normal on intravenous pyelography. A laparoscopy was scheduled.
Case Reports Patient No. 1 A 29-year-old nulliparous woman complained of infertility and dysmenorrhea of 2.5 years' duration. She had no significant medical or surgical history. Her
Operative Procedure The unicornuate uterus sounded to 7 cm and was deviated slightly to the left. A HUMI uterine
From the New York University Medical Center, New York, New York (all authors). Address reprint requests to Jamie A. Grifo, M.D., N.Y.U Medical Center, Division Reproductive Endocrinology, 317 East 34th Street 4th floor, New York, NY 10016; fax 212 263 7853.
491
Noncommunicating Uterine Horn Giatras and Grifo
Mild endometriosis at the right ovary was coagulated with a bipolar probe. The final view of the pelvis is shown in Figure 2. Blood loss was minimal. The patient was discharged the next morning.
manipulator (Unimar Corp., Wilton, CT) was placed and a pneumoperitomeum was created with carbon dioxide (CO2) through a Veress needle. Four-puncture laparoscopy was performed with one ]0-mm infraumbilical and one 12-mm left suprapubic port, and two 5-mm suprapubic ports laterally on the fight and midline. Laparoscopy revealed normal left hemiuterus, tube, and ovary, and right rudimentary uterine horn with normal-appearing tube. The surface of the right ovary contained implants of endometriosis (Figure 1). There was free spill of dye through the unicornuate uterus out of the left fallopian tube. The appendix, liver, and gallbladder were normal. Using bipolar forceps, the fight round ligament was grasped, elevated, and coagulated. It was incised, opening up both anterior and posterior leafs of the broad ligament. The leaves of the broad ligament were then dissected using hydrodissection and blunt and sharp dissection. The right tubo-ovarian ligament was coagulated and cut, and the mesosalpinx was serially coagulated and clamped to its insertion in the rudimentary horn. This mobilized the ovary and the broad ligament, and exposed the ureter after much hydrodissection. The ureter was below the pedicle of the rudimentary horn, and therefore dissection was continued further. In the area where the uterine horn was connected to the unicornuate uterus, there was a small fibrous band that was also coagulated and resected. Once this was done, the fight tube and rudimentary horn were free. The specimen was morcellated, taken out through a 10,mm cannula, and sent for pathologic examination.
Postoperative Evaluation The pathology report revealed fragments of smooth muscle containing endometrial mucous lining. At follow-up, the patient declared complete resolution of dysmenorrhea. She was advised to have normal intercourse, and if she did not conceive in 6 months, consider other possibilities. She conceived spontaneously the year after the intervention. Her pregnancy was followed closely, but no complications occurred. At 41 weeks the woman spontaneously delivered a healthy girl (birth weight 3490 g, Apgar scores 9 at 1 and 5 min). Patient No. 2 A 25-year-old woman was evaluated for infertility after 4 years of trying to conceive, and for associated pelvic pain. Her medical and surgical history included laparoscopy at age 23 years at another center that confirmed a unicornuate uterus with a fight rudimentary noncommunicating horn. Gynecologic examination and evaluation of other systems were completely normal. Intravenous pyelography revealed absence of a right kidney and ureter. This unilateral right renal agenesis had caused secondary slight dilation of the left ureter as a result of the increased urine flow. Hysterosalpingogram showed a unicornuate appearance of the uterus and a single left tube with normal spill into the cul-de-sac.
FIGURE 1. In patient no. 1, left hemiuterus, normal tube and ovary, and right rudimentary horn with normal tube and ovary
FIGURE 2. Final view of the pelvis after [aparoscopic resection of the rudimentary horn.
with slight endometriosis.
492
August 1997, Vol. 4, No. 4
TheJournal of the American Association of Gynecologic Laparoscopists
Two clearly distinct uterine horns were seen on vaginal ultrasound, much larger on the left, measuring 7.5 x 4.6 x 3.3 cm, and the rudimentary one on the right measuring 4 x 3.9 x 3 cm. Both ovaries were within normal limits, measuring 3.4 x 3.3 x 2.5 cm on the right and 3 x 2.3 x 1.9 cm on the left. Operative laparoscopy revealed a left unicornuate uterus with normal left tube. Patency of the left tube was demonstrated with indigo carmine. The right rudimentary horn had a short tubal segment from which no dye spillage was seen. The right ureter was absent, consistent with the intravenous pyelogram. The operative procedure was similar to that in the first patient. The pathology report confirmed fragments of myometrium and proliferative endometrium. This patient conceived naturally a year after the procedure. At cesarean section, performed because of lack of progress after spontaneous rupture of membranes at 36 weeks, examination of the pelvis did not reveal any adhesions. The patient delivered a healthy boy (birth weight 2410 g, Apgar scores 7 at 1 min and 9 at 5 min).
side. 2 It is possible that surgical intervention can result in successful achievement and maintenance of pregnancy, but very few data exist to confirm this. It is certain that removing the rudimentary horn is also advisable for other reasons, such as rupture of the uterus when a pregnancy occurs in that part, avoidance of pelvic pain because of obstruction of menstrual egress, and to prevent endometriosis. Our experience suggests the need to remove the rudimentary horn of a unicornuate uterus, and supports the laparoscopic approach if such a decision is taken. Fertility of both of our patients was affected, as they conceived spontaneously in the first year after surgery. It is possible that surgery itself enhanced fertility, but more data are required to support this hypothesis. The procedure was effective in resolving the women's pelvic pain and dysmenorrhea. References 1. Kriplani A, Relan S, Mittal S, et al: Pre-rupture diagnosis and management of rudimentary horn pregnancy in the first trimester. Eur J Obstet Gynecol Reprod Biol 58(2):203-205, 1995
Discussion
2. Andrews M, Jones HW Jr: Impaired reproductive perforrnance of the unicornuate uterus: Intrauterine growth retardation, infertility, and recurrent abortion in five cases. Am J Obstet Gynecol 144(2): 173-176, 1992
Despite the fact that the frequency of congenital mullerian abnormalities is 3%, unicornuate uterus with rudimentary noncommunicating horn is rare and not well documented?. 4 Approximately 90% of rudimentary horns are noncommunicating, and there is a risk of pregnancy occurring in the horn by transperitoneal migration of either sperm or fertilized ovum. l' 5 Women's reproductive potential may be affected by such abnormalities, 5 and may be improved after removal of the rudimentary horn. A possible explanation is that the horn may divert blood from the unicornuate uterus because of frequent absence of the uterine artery and utero-ovarian artery on the undeveloped
3. Greiss FC, Mauzy CH: Genital anomalies in women: An evaluation of diagnosis, incidence, and obstetric performance. Am J Obstet Gynecol 82:330-331, 1961 4. Schattman GL, Grifo JA, Birnbaum S: Laparoscopic resection of a noncommunicating rudimentary uterine horn. J Reprod Med 40(3):219-220, 1995 5. O'Leary JL, O'Leary JA: Rudimentary horn pregnancy. Obstet Gynecol 22(3):371-375, 1963
493
TheJournal of the American Associationof Gynecologic Laparoscopists
Laparoscopic Resection of a Noncommunicating Rudimentary Uterine Horn Konstantinos Giatras, M.D., Frederick L. Licciardi, M.D., and Jamie A. Grifo, M.D., Ph.D. Abstract Two women had infertility due to a symptomatic unicornuate uterus associated with rudimentary contralateral horn. Both carried successful pregnancies after laparoscopic resection of the horns. (J Am AssocGynecol Laparosc 4(4):491-493, 1997)
Unicornuate uterus with rudimentary horn is a rare mullerian abnormality that results from arrest in the development of one of the mullerian ducts and inappropriate fusion with the contralateral side. 1 Both unicornuate uterus and rudimentary horn containing an endometrial cavity are associated with various reproductive difficulties. 2 This mullerian abnormality can cause variable complications, such as hematometra and endometriosis, leading to acute abdominal pain, infertility, and obstetric complications. These include miscarriage, preterm delivery, or rupture of the uterus, especially when the pregnancy occurs in the rudimentary horn. Resection of the rudimentary horn in symptomatic, infertile women is indicated.
gynecologic history was marked by regular cycles with aggravated dysmenorrhea in the previous 2 years. She took oral contraceptives for 5 years, which she ceased because she wanted to conceive. Gynecologic examination revealed complete maturation of secondary sex characteristics with normal vulva, labia majora and minora, and clitoris. Speculum examination showed a single normal cervix and normal vagina. Bimanual examination revealed a deviated uterus to the left with perception of a right small mass. On hysterosalpingogram, a unicornuate uterus was deviated to the left side, with normal spill of dye from that tube. No communication with the rudimentary horn was noted. Vaginal ultrasound showed a uterus with functioning endometrium with a small right adnexal mass. Both kidneys and ureters were normal on intravenous pyelography. A laparoscopy was scheduled.
Case Reports Patient No. 1 A 29-year-old nulliparous woman complained of infertility and dysmenorrhea of 2.5 years' duration. She had no significant medical or surgical history. Her
Operative Procedure The unicornuate uterus sounded to 7 cm and was deviated slightly to the left. A HUMI uterine
From the New York University Medical Center, New York, New York (all authors). Address reprint requests to Jamie A. Grifo, M.D., N.Y.U Medical Center, Division Reproductive Endocrinology, 317 East 34th Street 4th floor, New York, NY 10016; fax 212 263 7853.
491
Noncommunicating Uterine Horn Giatras and Grifo
Mild endometriosis at the right ovary was coagulated with a bipolar probe. The final view of the pelvis is shown in Figure 2. Blood loss was minimal. The patient was discharged the next morning.
manipulator (Unimar Corp., Wilton, CT) was placed and a pneumoperitomeum was created with carbon dioxide (CO2) through a Veress needle. Four-puncture laparoscopy was performed with one ]0-mm infraumbilical and one 12-mm left suprapubic port, and two 5-mm suprapubic ports laterally on the fight and midline. Laparoscopy revealed normal left hemiuterus, tube, and ovary, and right rudimentary uterine horn with normal-appearing tube. The surface of the right ovary contained implants of endometriosis (Figure 1). There was free spill of dye through the unicornuate uterus out of the left fallopian tube. The appendix, liver, and gallbladder were normal. Using bipolar forceps, the fight round ligament was grasped, elevated, and coagulated. It was incised, opening up both anterior and posterior leafs of the broad ligament. The leaves of the broad ligament were then dissected using hydrodissection and blunt and sharp dissection. The right tubo-ovarian ligament was coagulated and cut, and the mesosalpinx was serially coagulated and clamped to its insertion in the rudimentary horn. This mobilized the ovary and the broad ligament, and exposed the ureter after much hydrodissection. The ureter was below the pedicle of the rudimentary horn, and therefore dissection was continued further. In the area where the uterine horn was connected to the unicornuate uterus, there was a small fibrous band that was also coagulated and resected. Once this was done, the fight tube and rudimentary horn were free. The specimen was morcellated, taken out through a 10,mm cannula, and sent for pathologic examination.
Postoperative Evaluation The pathology report revealed fragments of smooth muscle containing endometrial mucous lining. At follow-up, the patient declared complete resolution of dysmenorrhea. She was advised to have normal intercourse, and if she did not conceive in 6 months, consider other possibilities. She conceived spontaneously the year after the intervention. Her pregnancy was followed closely, but no complications occurred. At 41 weeks the woman spontaneously delivered a healthy girl (birth weight 3490 g, Apgar scores 9 at 1 and 5 min). Patient No. 2 A 25-year-old woman was evaluated for infertility after 4 years of trying to conceive, and for associated pelvic pain. Her medical and surgical history included laparoscopy at age 23 years at another center that confirmed a unicornuate uterus with a fight rudimentary noncommunicating horn. Gynecologic examination and evaluation of other systems were completely normal. Intravenous pyelography revealed absence of a right kidney and ureter. This unilateral right renal agenesis had caused secondary slight dilation of the left ureter as a result of the increased urine flow. Hysterosalpingogram showed a unicornuate appearance of the uterus and a single left tube with normal spill into the cul-de-sac.
FIGURE 1. In patient no. 1, left hemiuterus, normal tube and ovary, and right rudimentary horn with normal tube and ovary
FIGURE 2. Final view of the pelvis after [aparoscopic resection of the rudimentary horn.
with slight endometriosis.
492
August 1997, Vol. 4, No. 4
TheJournal of the American Association of Gynecologic Laparoscopists
Two clearly distinct uterine horns were seen on vaginal ultrasound, much larger on the left, measuring 7.5 x 4.6 x 3.3 cm, and the rudimentary one on the right measuring 4 x 3.9 x 3 cm. Both ovaries were within normal limits, measuring 3.4 x 3.3 x 2.5 cm on the right and 3 x 2.3 x 1.9 cm on the left. Operative laparoscopy revealed a left unicornuate uterus with normal left tube. Patency of the left tube was demonstrated with indigo carmine. The right rudimentary horn had a short tubal segment from which no dye spillage was seen. The right ureter was absent, consistent with the intravenous pyelogram. The operative procedure was similar to that in the first patient. The pathology report confirmed fragments of myometrium and proliferative endometrium. This patient conceived naturally a year after the procedure. At cesarean section, performed because of lack of progress after spontaneous rupture of membranes at 36 weeks, examination of the pelvis did not reveal any adhesions. The patient delivered a healthy boy (birth weight 2410 g, Apgar scores 7 at 1 min and 9 at 5 min).
side. 2 It is possible that surgical intervention can result in successful achievement and maintenance of pregnancy, but very few data exist to confirm this. It is certain that removing the rudimentary horn is also advisable for other reasons, such as rupture of the uterus when a pregnancy occurs in that part, avoidance of pelvic pain because of obstruction of menstrual egress, and to prevent endometriosis. Our experience suggests the need to remove the rudimentary horn of a unicornuate uterus, and supports the laparoscopic approach if such a decision is taken. Fertility of both of our patients was affected, as they conceived spontaneously in the first year after surgery. It is possible that surgery itself enhanced fertility, but more data are required to support this hypothesis. The procedure was effective in resolving the women's pelvic pain and dysmenorrhea. References 1. Kriplani A, Relan S, Mittal S, et al: Pre-rupture diagnosis and management of rudimentary horn pregnancy in the first trimester. Eur J Obstet Gynecol Reprod Biol 58(2):203-205, 1995
Discussion
2. Andrews M, Jones HW Jr: Impaired reproductive perforrnance of the unicornuate uterus: Intrauterine growth retardation, infertility, and recurrent abortion in five cases. Am J Obstet Gynecol 144(2): 173-176, 1992
Despite the fact that the frequency of congenital mullerian abnormalities is 3%, unicornuate uterus with rudimentary noncommunicating horn is rare and not well documented?. 4 Approximately 90% of rudimentary horns are noncommunicating, and there is a risk of pregnancy occurring in the horn by transperitoneal migration of either sperm or fertilized ovum. l' 5 Women's reproductive potential may be affected by such abnormalities, 5 and may be improved after removal of the rudimentary horn. A possible explanation is that the horn may divert blood from the unicornuate uterus because of frequent absence of the uterine artery and utero-ovarian artery on the undeveloped
3. Greiss FC, Mauzy CH: Genital anomalies in women: An evaluation of diagnosis, incidence, and obstetric performance. Am J Obstet Gynecol 82:330-331, 1961 4. Schattman GL, Grifo JA, Birnbaum S: Laparoscopic resection of a noncommunicating rudimentary uterine horn. J Reprod Med 40(3):219-220, 1995 5. O'Leary JL, O'Leary JA: Rudimentary horn pregnancy. Obstet Gynecol 22(3):371-375, 1963
493