Uterine horn and it’s management

o   Ms S

o   40 y nulliparous lady

o   Complaining of chronic pelvic pain and severe dysmenorrhoea for the past few years, worsened over the past few months. She was also concerned about her future fertility options.

o   USG showed a unicornuate uterus with a left sided uterine horn with an endometrial cavity; these findings were confirmed by MRI.

o   Patient underwent

o   Diagnostic and operative hysteroscopy with lateral metroplasty

o   Diagnostic and operative laparoscopy with resection of the rudimentary horn and fulguration of endometriotic lesions

o   Findings on Surgery:

On hysteroscopy:

§  Unicornuate small uterine cavity

§  Right side ostia visualized

§  All 4 walls normal

§  Cervical canal normal

On laparoscopy:

§  Unicornuate uterus with left sided non communicating rudimentary horn with an endometrial cavity

§  b/l tubes normal

§  B/l ovaries: endometriotic spots seen

§  Endometriotic spots on the utero-sacral ligaments

§  Bowel adherent to left pelvic wall

·         Histopathology:

oSection shows endometrium composed of tubular and straight glands lined by columnar epithelium. No mitosis seen. Myometrium unremarkable. (Compatible with rudimentary horn; weakly proliferative endometrium)

·    Discussion/ Practical Points

o  The gold standard for diagnosing Mullerian anomalies is hysteroscopy and laparoscopy

o  Excision of the rudimentary horn in most cases is similar to that of hysterectomy. Separation of   the horn from the uterus is easy when there is merely a band of fibrous tissue between them. It becomes more complex when the horn is closely attached to the uterus.

o Endometriosis is a commonly found associated pathology seen in women with functioning endometrium in the rudimentary horn and this can add to her symptoms. Hence excision of cavitated rudimentary horns is recommended to reduce the possibility of this occurring or reduce the severity of it.

o The excised rudimentary horn is ideally extracted intact either by a colpotomy incision or an extended lateral port so as to allow confirmation whether the horn is cavitated or not as morcellation may make it difficult to identify the endometrium. In our case, we have cut open the horn in situ (prior to morcellation) and determined that the horn contained an endometrial cavity. We therefore

o  Hysteroscopic lateral metroplasty will increase the size of the small cavity of the uterus and will help the patient later when planning conception.

o Changes in classification of Uterine Anomalies

Ø  According to the American Fertility Society Classification, this type of rudimentary horn falls under Class II (b).

Ø  However, the European Academy for Gynaecological Surgery (EAGS) has proposed a new classification system for Mullerian anomalies. This proposal has been also adopted as the scientific basis for the development of a new classification system by the common working group meanwhile established by the European Society of Human Reproduction and Embryology (ESHRE) and European Society for Gynaecological Endoscopy (ESGE) under the working name CONUTA (CONgenital UTerine Anomalies).

Ø  The updated new proposal for the classification of uterine congenital anomalies is designed having mainly clinical orientation and based on a critical review of the available data on female genital tract malformations with their extensive interpretation.

Ø  Under this new classification system, the above case falls under Class IV (a)

(Ref: Grigoris F. Grimbizis, Rudi Campo and On behalf of the Scientific Committee of the Congenital Uterine Malformations (CONUTA). Clinical approach for the classification of congenital uterine malformations. Gynecol Surg. 2012 May; 9(2): 119–129.)