Laparoscopichemihysterectomy on rudimentary non communicating functional horn in

unicornuate uterus on virgointacta: a case report

Florencia Wirawan, M. LukySatriaMarwali, Shirley Anggraini T
Department of Obstetric and Gynecology Fatmawati Hospital, Jakarta
(NB: Laparoscopic Procedure Video is Available for Scientific Usage)

Abstract
Objective: to share the implementation of laparoscopy for managing rudimentary non-communicating
functional horn in unicornuate uterus on virgointacta.
Methods: case report.
Case:Ms A, 21-yo, virgointacta consulted with episodes of intractable dysmenorrhea (VAS Score 5-6) which
elevated (VAS Score 8) since 1 month before admission. Transrectal ultrasound showed a non-communicating
rudimentary hornin unicornuate uterus. MRI showed a bicolis-didelphys uterus with vaginal duplication and
right hydrosalpinx. Laparoscopy visualized a non-communicatingrudimentary horn with unicornuate uterus and
hematosalpinx.A hemihysterectomy with right salpingectomy was done and evacuated by morcelator.
Dysmenorrhea complaint was gone (VAS 0). Pathology anatomy confirmed an adenomiosis and salpingitis
findings.
Conclusion:Laparoscopic approach shows a superb performance for managing rudimentary non-communicating
functional horn in unicornuate uterus on virgointacta, in form of direct visualization for diagnostic and operative
necessity until better cosmetic scar. An accurate preoperative diagnostic will ease laparoscopic procedure and
reduce probable complication.

Keywords: laparoscopy, unicornuate uterus, mullerian anomalies, dysmenorrhea

Correspondence: Florencia Wirawan, florencia.wirawan@gmail.com

INTRODUCTION CASE PRESENTATION

Unicornuate uterus with rudimentary uterine
horn is a class II reproductive tract congenital
anomaly that can lead to deliberating pain or
devastating reproductive complications such as
ectopic pregnancy or ruptured
uterus.1Unicornuate uterus contributed at 13%
of all Mullerian Duct Anomalies. Unicornuate
uterus with rudimentary horn occurs when
paramesonephric ducts failed to fuse in the
midline and canalized between the 7 th and 8th
week of gestation.1 Rudimentary horn with
functional endometrium cause blood
accumulation within the uterine cavity and
surgical excision is necessary to mollify the
symptoms.1,2 Advance approach with
laparoscopy is developing in OB/GYN
diagnostic and surgical field area in Indonesia,
thus we assume that this approach could
contribute as a better approach option either as
an adjunct diagnostic tool or surgical
management for mullerian duct anomalies
cases.
Ms A, 21 yo, a virgointacta consulted to
general gynecology outward clinic for cyclic
pelvic pain. She reported episodes of
intractable dysmenorrhea (VAS Score 5-6).
Pain severity elevated (VAS Score 8) since 1
month before admission. Her menstrual cycle
was regular within 4 – 5 days, cycle of 33
days. Patient lost 4 kilogram of body weight in
past 2 months due to severe nausea. She had
mild dyzchezia (VAS Score 2-3) and dysuria
was denied. The clinical examination showed
a normal secondary sex development.
Abdominal mass was palpable located at 1
finger above the pubic symphysis. Via
inspection, a normal vulva, OUE and intact
hymen were visualized. Speculum insertion
was not done. Digital rectal examination
showed a normal sized uterus but pain was felt
and mass was palpated on the right adnexa
with limited mobility, no bulge was found at
the recto-uterine pouch.
Transrectal ultrasonography showed 2 fundal
with 2 uterine cavities, correspond with 2 horn
uterus. No abnormality was found on the left
horn cavity, regular endometrium, connected
with normal cervical canal. Left horn had
echointernal material inside, no connection to
the cervical canal, thus we suspected a non
communicating rudimentary horn. No defect
on both kidney or other urinary tracts.
Magnetic resonance imaging was done in the
next day, and showed a bicolisdidelphys type
of mullerian anomaly with vaginal duplication,
and a right hydrosalpinx. Patient was
consulted to the urogynecology department,
and ultrasound examination was repeated due
to different diagnosis of the two modalities.
Ultrasound showed a non communicating
unicornuate uterus with hematometra and
hematosalpinx.

Figure 2. USG finding for both kidneys

Figure 1. Hematometra and one normal horn

finding in TRUS
Figure 3. bicolisdidelphys with vaginal
duplication and right hydrosalpinx
Since the final diagnosis was a symptomatic
non communicating horn, patient was
scheduled for a laparoscopic
hemihysterectomy and right
salpingectomy.Laparoscopy visualization
showed no adhesion with the peritoneum,
unicornuate non communicating uterus with
left horn connected with the vagina and
normal left ovarium. There was no connection
between right horn with the vagina. There
were right hematosalphinx. A infertile and who have had repeated
hemihysterectomy with right salpingectomy
was done. The hysterectomized uterus was
evacuated by morcelator. Net operation time
was 3 hours without any intraoperative
complication.
Figure 4. Laparoscopic intraoperative
visualization for normal left horn and right
hematometra horn with hematosalpinx
Figure 5. Laparoscopic intraoperative
visualization for normal left horn, right
hematometra, vagina and right ovarium
In the inward department, no postoperative
complication was found. Patient discharge
after 2 dayspost procedure. On the follow up,
dysmenorrhea complaint was gone. Pathology
anatomy confirmed an adenomiosis and
salpingitis findings.
DISCUSSION
Uterine anomalies are present in 0.5-2.0% of
women, this rate is higher in women who are
miscarriages.1 Attempts have been made to
classify uterine anomalies. Perhaps the most
widely accepted classification system for
uterine anomalies is from the American
Fertility Society.3,4 This classification
organized the anomalies into six major uterine
anatomic types.4 The resulting anomalies can
be considered to be due to one of four events
1. Failure of one or more of the
mullerian ducts to develop – agenesis,
unicornuate uterus without
rudimentary horn
2. Failure of the ducts to canalize –
unicornuate uterus with rudimentary
horn
3. Failure of or abnormal fusion of the
ducts – uterus didelphys, bicornuate
uterus
4. Failure of the reabsorption of the
midline uterine septum – septate
uterus, arcuate uterus
Unicornuate uterus with rudimentary horn
occurs when paramesonephric ducts failed to
fuse in the midline. The lack of
paramesonephric ducts fusion combined with
deficiency of cannulation or a regression
mediated by apoptosis leads to variation of
clinical findings.3,4 This includes unicornuate
uterus with and without rudimentary horn.
When a rudimentary horn is present, it may or
may not communicate with the unicornuate
uterus, and it may or may not containing
functioning endometrium. Further more the
attachment of the rudimentary horn to the
unicornuate uterus can vary between direct,
miometrial attachment and fibrous band
attachment. 44% of the mullerian anomalies incisional scar which surely will please the
are associated with urologic abnormality such patient more. Pathology anatomy finding
as ipsilateral kidney development (67%) or showed an adenomiosis, this finding could
horseshoe kidney (13%). occur because of the obscurity of morcelated
uterus. But according to available literature,
Unicornuate uterus results from normal there was a correlation between a functional
differentiation of only one mullerian duct. This non communicating horn with endometriosis
may present with miscarriage or preterm due to retained menstrual blood which suited
delivery. One study demonstrated a preterm the Sampson theory.2,9
delivery rate of 25% and early miscarriage rate CONCLUSION
of 37.5%.5 Non communicating rudimentary Laparoscopic approach shows a superb
horns with functional endometrium usually performance for managing rudimentary non-
present with pain; this necessitates the removal communicating functional horn in unicornuate
of the horn, which may be carried out uterus on virgointacta. Theaccurate
laparoscopically5,6. Removal of the horn is preoperative diagnostic will ease laparoscopic
essential as pregnancy may occur within the procedure and reduce probable complication.
horn. There have been reports of removal of
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