Journal of minimally invasive gynecology 2017 06 21() pii S1553-4650(17)30361-8
To demonstrate a step by step surgical hysteroscopy technique in a patient with asymmetric uterine septum and transverse uterine septum that was not previously described in the literature.
Resection of a asymmetric uterine septum by laparoscopy and ultrasound-guided hysteroscopy (Canadian Task Force Classification III). The video was assumed exempt from official review by our institutional review board.
A septate uterus is defined as the uterus in which the uterine cavity is longitudinally divided by the septum (1). The most common uterine anomaly, septate uterus has a spectrum of configurations ranging from complete septate to incomplete septate uterus. Asymmetric uterine septum was reported only as case reports in the literature and is described as Robert’s uterus (2). This unique malformation is described as a septate uterus with a non-communicating hemicavity, composing a blind uterine horn usually with unilateral hematometra, a contralateral unicornuate uterine cavity. The external uterine shape is normal. The assymmetric septum with transverse uterine septum in the present case has not yet been reported in the literature.
A 29-year-old woman presented to our clinic with primary amenorrhea, cyclic pelvic pain, and the desire to have pregnancy. She previously had failed 2 laparoscopy and hysteroscopy for fertility treatments. Hysterosalpingography previously had been failed. The patient had been previously applied magnetic resonance imaging. In the magnetic resonance imaging report, it was written that there was no connection between the uterus and cervix. On external genital organs assessment, there was no abnormal sign. Ultrasonography revealed two uterine cavities and hematometra. Both ovaries were in normal view.
In view of her examination findings, the patient was scheduled laparoscopy and hysteroscopy. Laparoscopy revealed extensive adhesions on both the pelvis and upper abdomen. Initially, uterus and ovaries were not visualized. Adhesiolysis was performed and normal anatomy was restored. After this step, the operation was continued by laparoscopy and ultrasound-guided hysteroscopy. Under the ultrasound and laparoscopy guidence transverse uterine septum at the level of uterine isthmus was incised and the left endometrial cavity was observed with hysteroscopy. The asymmetric uterine septum was then incised and the right sided endometrial cavity was then accessed. Finally uterine septum was comletely incised and the both sided endometrial cavities were merged. The patient had an uncomplicated postoperative course and was discharged 24 hours after surgery. She returned for follow-up examination in the second month after surgery. She had regular menstrual cycles and her pain was cured.
Hysteroscopy and laparoscopy combined with ultrasound is a useful method for the diagnosis and treatment of assymmetric uterine septum. The skill and experience of the laparoscopic surgeon is also another important factor for identify and manage the unusual uterine malformations.