Conservative treatment for a noncommunicating rudimentary uterine horn

Unicornuate uterus is caused by the non development of one Müllerian duct and accounts for 5% of all congenital uterine anomalies. The objectives of surgical treatment are pain relief and maintenance and/or improvement of the reproductive capacity. The present paper reports a laparoscopic/hysteroscopic conservative management of unicornuate uterus. The patient was a 12-year-old nulligravida, white, single female and was not sexually active. Menarche was with 10 year-old, followed by regular periods (4–5 days in duration). One year after menarche, she started with midlower abdominal pain and progressive dysmenorrhea. In the last 6 months she had noticed a hard abdominal mass and complained of pain during the menses. On this occasion an ultrasound examination showed a uterus (7.7×4.6×3.8 cm) with high density secretion. Just one kidney could be identified. After obtaining her fully informed consent, the patient underwent diagnostic laparoscopy that demonstrated a right unicornuate uterus with left rudimentary uterine horn dilated by a large hematometra and hematosalpinx. There was blood in the abdominal cavity with several foci of endometriosis, adherence of intestine to the small pelvis wall and cul-de-sac. The rudimentary horn was enlarged (2× the right unicornuate uterus). Left salpingectomy, and cauterization of endometriotic foci were performed. The rudimentary horn cavity was then opened via vaginalis and cannulated, permitting the drainage of the hematometra. During the follow up hysteroscopy, functional endometrium in the rudimentary horn was identified. After 2 cycles, a vaginal ultrasound showed a hematometra, despite the permeability of the vaginal orifice.A hysteroscopy with endometrial ablation with roller ball was performed. In two years follow up the patient is totally asymptomatic, and the ultrasound examination did not show endometrial line in the uterine rudimentary horn. The unicornuated uterus with noncommunicating rudimentary horn was present in 36% of the unicornuated uteruses in a recent review (1). This anomaly is not the most frequent but it is the most clinically significant because it is associated frequently with progressive severe dysmenorrhea, hematometra, pyometra (2) and endometriosis due to retrograde menstruation (3). Salpingectomy homolateral to the rudimentary horn should be made in order to avoid ectopic pregnancy. For surgical approach it is important to know the anatomical presentation of the rudimentary horn, that could be fixed or separated from the unicornuate uterus (4). Separated horn occurs when there is no fusion with the contralateral duct, and a fibrous band usually connects the two horns to the unicornuate uterus. In this case, the blood supply (uterine artery) is found below the fibrous band and is easily identified and ligated or coagulated. When the rudimentary horn is firmly attached to the unicornuate uterus, blood supply can be found lateral to the unicornuated uterus, and the supply to the rudimentary horn is not as easily identified and dissected, as it is contiguous with the underlying myometrium. There is a higher probability of dissecting into the uterine artery, with resultant heavy bleeding and possible compromise of myometrial wall thickness (5). In the first laparoscopy the homolateral fallopian tube should be removed in order to avoid ectopic pregnancy (1). The approach presented in this paper is an alternative for those cases in which the blood supply to the rudimentary horn is not easily identified. It diminishes surgical bleeding complications and avoids injury to the unicornuate uterus myometrial wall.