Accessory and Cavitated Uterine Mass (ACUM) in an 18-Year-Old Woman: A Case Report and Literature Review

Background Accessory and cavitated uterine mass (ACUM) is a rare uterine anomaly newly recognized as a form of developmental Mullerian anomaly, which represents a non-communicating uterus-like mass within an otherwise normal uterus. It is a benign gynecological disease associated with severe dysmenorrhea and chronic pelvic pain, which is most common in young nullipara women, and sometimes develops in parous women. Clinical manifestations combined with imaging examinations including ultrasonography (USG), magnetic resonance imaging (MRI), and hysterosalpingography (HSG) are the means to establish a correct diagnosis. Medical therapy is only marginally effective, but laparoscopic surgery for complete mass excision is a feasible technique to relieve patient’s symptoms. Our article is aimed to report a case of ACUM in an 18-year-old woman and summarize the diagnostic criteria of ACUM. Case presentation : An 18-year-old woman was admitted for severe pain in the right lower abdomen during menstruation, which lasted more than 1 year. The patient was misdiagnosed with focal adenomyosis at our hospital on March 4, 2021. After 4 months, she was diagnosed with ACUM. Once diagnosis as focal adenomyosis, nonsteroidal anti-inflammatory drugs (NSAIDs) and gestrinone were administered to the patient. Following the diagnosis of ACUM, she received laparoscopic surgery. Our follow-up indicated that the symptom was significantly relief without drug therapy after sixty days postoperatively. Conclusions Clinical manifestations and imaging examinations are used to establish the diagnosis of ACUM. Medical therapy is only marginally effective, but laparoscopic surgery for complete mass excision is a feasible technique to solve the pain symptom. The prevalence and pathogenesis of ACUM and its reproductive outcomes on patients remain unclear, which calls for more and deeper research to study.

Imaging Manifestations of Accessory Cavitated Uterine Mass—A Rare Mullerian Anomaly

Context Accessory cavitated uterine mass (ACUM) is an uncommon and under-recognized entity with distinct imaging characteristics and causing significant patient distress. Differentiating it from its other clinical and radiological differentials is therefore extremely important and prevents delay in surgical management which is the treatment of choice. Aims The aim of the study is to describe the MRI appearance of the surgically and pathologically proven ACUM cases from our institution in the last 2 years. Settings and Design This is a retrospective study in a tertiary care hospital in South India. Methods and Material We reviewed the clinical presentations and imaging findings of seven surgically proven cases of ACUM qualifying the proposed diagnostic criteria. Results All patients presented with chronic pelvic pain, dysmenorrhea, and prolonged post-menstrual pain. MRI in all seven cases showed an intramural, noncommunicating, and cavitating lesion near the uterine cornua with internal contents similar to that of endometrioma. Although the cavity was lined by endometrium in all the cases (proven in pathology), it was well appreciable on MRI in only five cases. The rest of the uterine myometrium and main endometrial cavity were normal with no features of adenomyosis. Conclusion MRI is a reliable diagnostic tool for accurate diagnosis of ACUM, and more importantly, in distinguishing it from other causes of chronic pelvic pain like adenomyosis and endometriosis and other imaging differentials like adenomyoma, noncommunicating uterine horn, and degenerating leiomyoma.

SURGICAL RECONSTRUCTION (UTEROVAGINAL ANASTOMOSIS) USING AUTOLOGOUS PERITONEUM (DAVYDOV’S PROCEDURE) IN A CASE OF CERVICAL AGENESIS

Cervical agenesis is a rare Mullerian anomaly requiring surgical reconstruction to restore the uterovaginal canal and thus menstruation in such patients. In the past, treatment in such patients was hysterectomy which has now developed into more conservative approach. We describe a successful canalization of the uterovaginal canal using autologous peritoneum in a case of cervical agenesis

Uterine Didelphys with Transverse Vaginal Septum – A Complex rare Müllerian anomaly

During the development of the female genital tract, any insult to the normal development process results in a set of intriguing abnormalities known as Müllerian duct abnormalities. The uterine didelphys is the second least common type of anomaly among these, which may commonly be associated with a longitudinal vaginal septum (lateral fusion defect). However uterine didelphys along with a transverse vaginal septum (lateral fusion plus resorption defect) is a very rare finding and to the best of our knowledge, thecase that we hereby report is the second one in literature.A 16-year-old unmarried girl presented with primary amenorrhoea and cyclical pain for 18months.On clinical examination and imaging, a case of uterine didelphys and transverse vaginal septum was found. Her urinary tract was normalon USG and MRI evaluation. Excision of the septum was done by abdomino-vaginal approach. The patient was discharged well.We conclude that a patient presenting with primary amenorrhea especially with cyclical dysmenorrhea with a transverse vaginal septum on examination should be thoroughly investigated for associated upper genital tract abnormalities as the treatment strategy and prognosis is largely dependent on the correct classification of the anomaly.

Inappropriate surgery in a patient with misdiagnosed Robert’s uterus

Background Robert’s uterus is a rare Mullerian anomaly, which can be described as an asymmetric, septate uterus with a non-communicating hemicavity. Herein, we present the case of a misdiagnosed Robert’s uterus, resulting in an invasive and disadvantageous surgery. Case presentation A 16-year-old woman was referred to our department because of dysmenorrhea and suspicion of uterine malformation. We misdiagnosed Robert’s uterus as a unicornuate uterus with a non-communicating rudimentary horn and hematometra, and performed laparoscopic hemi-hysterectomy. Although the patient’s symptoms were relieved, our surgical procedure left the lateral uterine wall weak, making the patient’s uterus susceptible to uterine rupture in any future pregnancy. Conclusions Although the early diagnosis of Robert’s uterus is challenging, it is important in order to determine appropriate surgical interventions and management for maintaining the quality of life and ensuring safety in future pregnancies.

Congenital Obstructive Müllerian Anomaly: The Pitfalls of a Magnetic Resonance Imaging-Based Diagnosis and the Importance of Intraoperative Biopsy

A retrospective cohort study of the concordance between the magnetic resonance imaging (MRI) diagnosis and final diagnosis in patients with Müllerian duct anomalies (MDAs) was conducted, and diagnostic clues were suggested. A total of 463 cases of young women who underwent pelvic MRIs from January 1995 to February 2019 at Seoul Asan Medical Center were reviewed. Interventions consisted of clinical examinations, abdominal or transvaginal/rectal ultrasound, MRI, and operative procedures, including hysteroscopy and laparoscopy. The concordance of the diagnosis between the results obtained with MRI and those obtained with surgeries was evaluated. It was found that a total of 225 cases (48.6%) showed genital tract anomalies on MRI. Among them, 105 cases (46.7%) underwent reconstructive surgery. Nineteen cases (8.4%) revealed discrepancies between the final diagnosis after surgery and the initial MRI findings and eleven cases (57.9%) had cervical anomalies. Incorrect findings associated with the MRIs were particularly evident in biopsied cases of cervical dysgenesis. A combination of physical examination, ultrasound, and MRI is suitable for preoperative work-up in the diagnoses of congenital obstructive anomalies. However, it is recommended that a pathologic confirmation of tissue at the caudal leading edge be made in obstructive genital anomalies, in cases of presumptive vaginal or cervical dysgenesis.

Unclassified Mullerian Anomaly: Retroperitoneal Uterus

Anomalies of uterus might be encountered at Caesarean Section or routine investigation. In this article, we present a rare case of double horns of uterus completely separated. One of them is situated retroperitoneally. Therefore, MRI or CT scans is recommend for unclassified Mullerian anomalies, to confirm pelvic or other anomalies and to reduce the likelihood of complications arising during the operation or delivery.