Human Reproduction vol.5 no.7 pp.819-820, 1990
CASE REPORT
Laparoscopic management of unicornuate uterus with rudimentary horn and unilateral extensive endometriosis: case report
Michel Canis1*3, Arnaud Wattiez1, Jean Luc Pouly1, Gerard Mage1, Hubert Manhes2 and Maurice Antoine Bruhat' 'Service Gynecologie Obstetrique et Biologie de la Reproduction, Polyclinique CHRU, 5 Boulevard Charles de Gaulle, 63000 Clermont Ferrand and -tlinique La Pergola, M\6e des Ailes, 03200 Vichy, France ^To whom correspondence should be addressed
One case of unicornuate uterus with a cavitary rudimentary horn and unilateral extensive endometriosis was treated by laparoscopy, after three months of treatment with GnRH analogues. The rudimentary horn and the corresponding tube were removed. The post-operative course was uneventful. Laparoscopic radical management of this malformation reduces both peritoneal damage and economic cost. Key words: laparoscopic treatment/unicornuate uterus
Introduction To prevent the risk of cornual pregnancies (Rock and Schlaff, 1985; Verbaere and Rochet, 1985) and of endometriosis (Buttram and Gibbons, 1979; Oliver and Henderson, 1987), contemporary management of asymmetric uterus with rudimentary hom should include the removal of the rudimentary horn (Rock and Schlaff, 1985). This report describes our first laparoscopic treatment of this malformation, using recent developments in operative laparoscopy (Bruhat et al., 1989).
action. Medical treatment for endometriosis using Triptoreline (Decapeptyl®, Ipsen Biotech Laboratories, Paris, France) for three months was prescribed. The intravenous pyelogram was normal and hysterosalpingography confirmed the diagnosis of a right unicornuate uterus with a non-communicating left rudimentary horn (class lib) (American Fertility Society, 1988). Laparoscopic removal of the left horn was indicated. After extensive discussion with the patient concerning the possible need for laparotomy, an informed consent was obtained. The second laparoscopic examination was performed on 10 September, 1988. The left salpingectomy was begun at the fimbriated end, and performed using bipolar coagulation and laparoscopic scissors. The left tube was used to pull up the rudimentary horn. The left uterus was dissected from the bladder using scissors, bipolar coagulation and hydrodissection. After extensive peritoneal lavage with saline, the peritoneal incision was closed using fibrin sealant (Tissucol®, Immunofrance Laboratories, Rungis, France). The left uterus was removed using a low transverse abdominal incision of 2 cm in length. The left ovarian endometrioma was removed by intraperitoneal cystectomy (Bruhat et al., 1989). Due to extensive and dense pelvic adhesions, the operating time was 3 h. The post-operative course was uneventful and the patient was discharged two days after the operation. Pathological examination showed a uterine cavity of 3 cm in length with a normal endometrium. Long-term follow-up has so far been uneventful. The patient is using oral contraception.
Discussion Case report A 30-year-old woman, gravida 1, para 0 (one previous voluntary abortion) was referred for surgical evaluation of an abdominal pelvic mass. The patient presented complaining of primary dysmenorrhoea with severe deep dyspareunia. Physical examination revealed a soft, fixed and tender abdomino-pelvic mass which extended to the umbilicus. Ultrasonic examination showed a multilocular cystic mass of 15 cm in diameter. As serum Ca 125 and erythrocyte sedimentation rate were within the normal range, surgical evaluation was undertaken by laparoscopy (Bruhat et al., 1989). Laparoscopy combined with hysteroscopy showed a right uni-cornuate uterus with a normal adnexa, a left noncommunicating rudimentary horn ( 4 x 3 x 2 cm) with an enlarged and thickened tube and an ovarian endometrioma of 15 cm diameter with dense adhesion to the sigmoid colon. As this diagnosis was previously unsuspected, additional radiological examination was undertaken in order to decide on the course of © Oxford University Press
From the literature, it appears that 75-90% of cases of unicornuate uterus with rudimentary hom are non-communicating (Buttram and Gibbons, 1979; Rock and Schlaff, 1985). Only 1 % of cornual gestations resulted in a live full-term birth (Buttram and Gibbons, 1979; Rock and Schlaff, 1985), whilst high rates of rupture (up to 89%) which may occur as early as the eleventh week have been reported. Based on these data, radical management of rudimentary hom was recommended by Rock and Schlaff (1985) and was also recommended in cases of non-communicating cavitary rudimentary horn, to avoid the risk of endometriosis (Buttram and Gibbons, 1979; Olive and Henderson, 1987). Although it is not clear whether or not the prognosis of a pregnancy is compromised by the presence of a rudimentary hom (Buttram and Gibbons, 1979; Fedele et al., 1987), it is our opinion that a non-communicating rudimentary hom should be removed. Associated salpingectomy is always advisable to prevent the risk of tubal pregnancies (Fedele et al., 1987). 819
M.Cants et al. Since this first case, we have treated two other cases of rudimentary horn by laparoscopy: one was discovered and treated during a laparoscopy performed for infertility; the second during the treatment of extensive endometriosis. The postoperative course was uneventful in both cases. Our experience shows that laparoscopic removal of rudimentary horns can be achieved under good conditions. This procedure should, however, be performed only by operators trained in extensive laparoscopic surgery. As this malformation is generally discovered in young patients, laparoscopic treatment is desirable to avoid unnecessary peritoneal damage, thus reducing postoperative adhesions.
References American Fertility Society (1988) Gassifications of adnexal adhesions, distal tube occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil. Steril., 49, 944-955. Buttram,V.C. and Gibbons.W.E. (1979) Mullerian anomalies: a proposed classification (an analysis of 144 cases). Fertil. Steril., 32, 40-46. Bruhat.M.A., Mage,G., Pouly,J.L., Manhes.H., Canis,M. and Wattiez.A. (1989) Coelioscopie Opiratoire. Ed MEDSI, McGraw Hill, Paris. Fedele,L., Zamberletti.D., Vercellini,P., Dorta.M. and Candiani.G.B. (1987) Reproductive performance of women with unicornuate uterus. Fertil. Steril, 47, 416-419. Olive,D.L. and Henderson,D.Y. (1987) Endometriosis and Mullerian anomalies. Obstet. Gynecol, 69, 412-415. Rock.J.A. and Schlaff.W.D. (1985) The obstetric consequences of uterovaginal anomalies. Fertil. Steril., 43, 681—691. Verbaere.S. and Rochet,Y. (1985) Les malformations uterines. Encycl. Med. Our. (Paris) Gynecologic. Fasc. 123A'°,6-1985, 16 p. Received on February 16, 1990; accepted on May 31, 1990
820
CASE REPORT
Laparoscopic management of unicornuate uterus with rudimentary horn and unilateral extensive endometriosis: case report
Michel Canis1*3, Arnaud Wattiez1, Jean Luc Pouly1, Gerard Mage1, Hubert Manhes2 and Maurice Antoine Bruhat' 'Service Gynecologie Obstetrique et Biologie de la Reproduction, Polyclinique CHRU, 5 Boulevard Charles de Gaulle, 63000 Clermont Ferrand and -tlinique La Pergola, M\6e des Ailes, 03200 Vichy, France ^To whom correspondence should be addressed
One case of unicornuate uterus with a cavitary rudimentary horn and unilateral extensive endometriosis was treated by laparoscopy, after three months of treatment with GnRH analogues. The rudimentary horn and the corresponding tube were removed. The post-operative course was uneventful. Laparoscopic radical management of this malformation reduces both peritoneal damage and economic cost. Key words: laparoscopic treatment/unicornuate uterus
Introduction To prevent the risk of cornual pregnancies (Rock and Schlaff, 1985; Verbaere and Rochet, 1985) and of endometriosis (Buttram and Gibbons, 1979; Oliver and Henderson, 1987), contemporary management of asymmetric uterus with rudimentary hom should include the removal of the rudimentary horn (Rock and Schlaff, 1985). This report describes our first laparoscopic treatment of this malformation, using recent developments in operative laparoscopy (Bruhat et al., 1989).
action. Medical treatment for endometriosis using Triptoreline (Decapeptyl®, Ipsen Biotech Laboratories, Paris, France) for three months was prescribed. The intravenous pyelogram was normal and hysterosalpingography confirmed the diagnosis of a right unicornuate uterus with a non-communicating left rudimentary horn (class lib) (American Fertility Society, 1988). Laparoscopic removal of the left horn was indicated. After extensive discussion with the patient concerning the possible need for laparotomy, an informed consent was obtained. The second laparoscopic examination was performed on 10 September, 1988. The left salpingectomy was begun at the fimbriated end, and performed using bipolar coagulation and laparoscopic scissors. The left tube was used to pull up the rudimentary horn. The left uterus was dissected from the bladder using scissors, bipolar coagulation and hydrodissection. After extensive peritoneal lavage with saline, the peritoneal incision was closed using fibrin sealant (Tissucol®, Immunofrance Laboratories, Rungis, France). The left uterus was removed using a low transverse abdominal incision of 2 cm in length. The left ovarian endometrioma was removed by intraperitoneal cystectomy (Bruhat et al., 1989). Due to extensive and dense pelvic adhesions, the operating time was 3 h. The post-operative course was uneventful and the patient was discharged two days after the operation. Pathological examination showed a uterine cavity of 3 cm in length with a normal endometrium. Long-term follow-up has so far been uneventful. The patient is using oral contraception.
Discussion Case report A 30-year-old woman, gravida 1, para 0 (one previous voluntary abortion) was referred for surgical evaluation of an abdominal pelvic mass. The patient presented complaining of primary dysmenorrhoea with severe deep dyspareunia. Physical examination revealed a soft, fixed and tender abdomino-pelvic mass which extended to the umbilicus. Ultrasonic examination showed a multilocular cystic mass of 15 cm in diameter. As serum Ca 125 and erythrocyte sedimentation rate were within the normal range, surgical evaluation was undertaken by laparoscopy (Bruhat et al., 1989). Laparoscopy combined with hysteroscopy showed a right uni-cornuate uterus with a normal adnexa, a left noncommunicating rudimentary horn ( 4 x 3 x 2 cm) with an enlarged and thickened tube and an ovarian endometrioma of 15 cm diameter with dense adhesion to the sigmoid colon. As this diagnosis was previously unsuspected, additional radiological examination was undertaken in order to decide on the course of © Oxford University Press
From the literature, it appears that 75-90% of cases of unicornuate uterus with rudimentary hom are non-communicating (Buttram and Gibbons, 1979; Rock and Schlaff, 1985). Only 1 % of cornual gestations resulted in a live full-term birth (Buttram and Gibbons, 1979; Rock and Schlaff, 1985), whilst high rates of rupture (up to 89%) which may occur as early as the eleventh week have been reported. Based on these data, radical management of rudimentary hom was recommended by Rock and Schlaff (1985) and was also recommended in cases of non-communicating cavitary rudimentary horn, to avoid the risk of endometriosis (Buttram and Gibbons, 1979; Olive and Henderson, 1987). Although it is not clear whether or not the prognosis of a pregnancy is compromised by the presence of a rudimentary hom (Buttram and Gibbons, 1979; Fedele et al., 1987), it is our opinion that a non-communicating rudimentary hom should be removed. Associated salpingectomy is always advisable to prevent the risk of tubal pregnancies (Fedele et al., 1987). 819
M.Cants et al. Since this first case, we have treated two other cases of rudimentary horn by laparoscopy: one was discovered and treated during a laparoscopy performed for infertility; the second during the treatment of extensive endometriosis. The postoperative course was uneventful in both cases. Our experience shows that laparoscopic removal of rudimentary horns can be achieved under good conditions. This procedure should, however, be performed only by operators trained in extensive laparoscopic surgery. As this malformation is generally discovered in young patients, laparoscopic treatment is desirable to avoid unnecessary peritoneal damage, thus reducing postoperative adhesions.
References American Fertility Society (1988) Gassifications of adnexal adhesions, distal tube occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil. Steril., 49, 944-955. Buttram,V.C. and Gibbons.W.E. (1979) Mullerian anomalies: a proposed classification (an analysis of 144 cases). Fertil. Steril., 32, 40-46. Bruhat.M.A., Mage,G., Pouly,J.L., Manhes.H., Canis,M. and Wattiez.A. (1989) Coelioscopie Opiratoire. Ed MEDSI, McGraw Hill, Paris. Fedele,L., Zamberletti.D., Vercellini,P., Dorta.M. and Candiani.G.B. (1987) Reproductive performance of women with unicornuate uterus. Fertil. Steril, 47, 416-419. Olive,D.L. and Henderson,D.Y. (1987) Endometriosis and Mullerian anomalies. Obstet. Gynecol, 69, 412-415. Rock.J.A. and Schlaff.W.D. (1985) The obstetric consequences of uterovaginal anomalies. Fertil. Steril., 43, 681—691. Verbaere.S. and Rochet,Y. (1985) Les malformations uterines. Encycl. Med. Our. (Paris) Gynecologic. Fasc. 123A'°,6-1985, 16 p. Received on February 16, 1990; accepted on May 31, 1990
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