Laparoscopic hemi-hysterectomy for complex obstructive mullerian anomalies: an extensive case series of young women presenting to the queensland paediatric and adolescent gynaecology (PAG) service between 2002 and 2019

Abstract

Objective Complex obstructive mullerian anomalies are sufficiently rare for most general gynaecologists to have had experience and confidence in recognition and management. This review represents the largest series of mullerian anomalies requiring hemi-hysterectomy in the literature. Diagnosis, management, surgical technique, MRI images, laparoscopic surgical images, and recordings will be presented. Design Retrospective review of mullerian anomalies requiring hemi-hysterectomy performed by Queensland PAG Services from 2002 to 2019. The PAG database and medical records provided relevant information on patient demographics, anatomical classification (ESHRE/ESGE), imaging, operative course, complications, and outcomes of subsequent pregnancies. Results 12 patients, aged 14-24 years, were identified as requiring hemi-hysterectomy. Six women had unicornuate uteri with a noncommunicating functional hemi-uterus (U4a), with two having unilateral absent kidney. Two adolescents had uterus didelphys, associated with unilateral cervical hypoplasia and unilateral cervical atresia, respectively (U3/C3), with absent ipsilateral kidney. One adolescent had a right TRIAD of uterine didelphys, obstructed right hemi-vagina with haematocolpos and absent right kidney (U3/C3/V2), who required hemi-hysterectomy for a hypoplastic right cervix with recurrent right haematometra, following septoplasty of the right hemi-vagina. One woman had a left functional hemi-uterus with a right hypoplastic uterine horn, associated with cervical atresia and absent upper vagina (U5/C4/V4). One patient had a left unicornuate uterus with a noncommunicating right hemi-uterus, and distal vaginal atresia (U4a/C3/V4) who required hemi-hysterectomy and creation of surgical-neovagina using a pull through procedure. One adolescent with bilateral functional hemi-uteri, with cervical and vaginal atresia, is awaiting surgery. All hemi-hysterectomies were done completely laparoscopically with mean operative time 2 hours, 22 min, and average length of stay 1.9 days (range 1-3 days). Six had endometriosis present, which was excised. All patients, other than the two with associated vaginal atresia, had hysteroscopy performed. Two patients required cystoscopy, with no bladder injuries observed. There were no major intraoperative or postoperative complications observed. Two patients have subsequently had two pregnancies each without complications, with deliveries by caesarean at 37-38 weeks. Conclusion An understanding of these complex anomalies is required for appropriate recognition, assessment, and management. Timely referral to specialist paediatric and adolescent gynaecologists streamlines care for this complex cohort of young women. Accurate and definitive preoperative diagnosis assists with planning, including counselling the patient and family, and consent. Close multidisciplinary collaboration with Advanced Laparoscopic Surgeons and Radiologists in specialised centres is essential for optimal outcomes.L6284730412019-07-16 <br />