Robert's uterus: modern imaging techniques and ultrasound-guided hysteroscopic treatment without laparoscopy or laparotomy

Ultrasonographic Imaging Features of Accessory Cavitated Uterine Malformations and Application to Diagnosis

OBJECTIVE

To analyze the ultrasonographic imaging features of accessory cavitated uterine malformations (ACUM) and discuss the practical value of ultrasonography in diagnosing this disease.

METHODS

A retrospective analysis was conducted on nine cases of ACUM diagnosed by ultrasound and confirmed by surgery and pathology at Peking University Shenzhen Hospital from October 2020 to August 2024. The ultrasonic imaging features of ACUM were summarized.

RESULTS

The average age of the nine patients with ACUM was 28.3 years (range: 18-39 years). Only one patient exhibited mild dysmenorrhea, while the remaining eight patients experienced severe and progressive dysmenorrhea. Among those with severe dysmenorrhea, the average age was 19.9 years (range: 13-38 years), and the mean time of onset after menarche was 6.5 years (range: 0-25 years). The results of preoperative ultrasonography were consistent with the surgical results, and the diagnostic coincidence rate was 100%. Preoperative ultrasound showed eight cases (88.9%) appeared as solitary lesions, and one case (11.1%) exhibited two cystic cavities on the same side of the uterus. Lesions were located on the anterior lateral wall of the uterus, below the uterine horn, with a median maximum diameter of (24.4 ± 3.6) mm. Lesions were round or oval and not connected to the uterine cavity, with clear boundaries, presenting as regular thick-walled cystic structures. Cystic areas were observed within the mass with a ground-glass-like appearance (88.9%) or hyperechoic (11.1%). The surrounding area of the mass showed resemblance to the muscular layer, and circular or semicircular vascularity was detected around the mass. No adenomyosis or other uterine lesions were found.

CONCLUSIONS

ACUM is a rare obstructive reproductive tract malformation that affects young women. Progressive aggravation of dysmenorrhea serves as its main clinical manifestation. ACUM exhibits distinct ultrasound characteristics; preoperative ultrasonography can be used to accurately diagnose ACUM through identification of typical manifestations, providing a reliable imaging basis for diagnosis and treatment management.

Robert's uterus treated with ultrasound-guided laparoscopy and hysteroscopy: a case report

We report the case of a woman in her early 30 s who was diagnosed with Robert's uterus. She had been experiencing progressive dysmenorrhea for a decade and sought treatment for infertility at our hospital. Preoperative ultrasound imaging resulted in a misdiagnosis of a complete uterine septum with an accompanying ovarian cyst. However, intraoperative ultrasound-guided laparoscopy and hysteroscopy confirmed the presence of an asymmetric mediastinal uterus with a blind cavity, consistent with Robert's uterus, along with endometriosis. We performed a combined hysteroscopy and laparoscopy to excise the septum and endometrial cyst in the uterine cavity, and we inserted a uterine cavity stent to prevent postoperative intrauterine adhesions. Subsequent evaluations confirmed the success of the surgical and postoperative treatment strategies. The findings in this case suggest that despite the risk of a misdiagnosis before surgery, accurate assessment and effective surgical intervention for Robert's uterus can be achieved by the combined application of hysteroscopy and laparoscopy, with guidance by ultrasound. Furthermore, our findings highlight the importance of addressing concurrent conditions in the management of Robert's uterus.

Minimally invasive surgical treatment of Robert's uterus with missed miscarriage: case report

Robert's uterus was firstly reported in 1970, it's a rare Müllerian duct anomaly with 2 intra-uterine cavities divided by asymmetrical septum. One of the cavities is completely obstructed to cervix by septum and menstruation fluid retents in this blind cavity, periodical pelvic pain during menstruation can lead attendance to hospital. We report a gravida of Robert's uterus with missed abortion in the blind cavity, who had mild dysmenorrhoea since adolescent age, diagnosed and treated by minimally invasive surgical methods. To our knowledge, it's a previously unreported case which gynaecologists terminated pregnancy in blind cavity of Robert's uterus without resecting the septum while dysmenorrhoea relieved entirely and postoperative volume of menstruation stayed the same as preoperative.

A new treatment for Robert's uterus with adenomyosis: a case report and review of the literature

PURPOSE

To provide a method for the differential diagnosis of Robert's uterus with adenomyosis, a rare uterine malformation, and determine the best course of treatment.

METHODS

A patient who had Robert's uterus with adenomyosis was admitted to our hospital in December 2022. We analyzed and summarized her case .

RESULTS

Our patient complained of progressively worsening primary dysmenorrhea over the course of 3 years and lower abdominal pain lasting for 2 days. Her carbohydrate antigen 125 (CA125) level was 372.10 U/mL. Examinations conducted by several hospitals indicated that she had a single-horned uterus and a residual horned uterus, and our hospital's examination identified Robert's uterus. This malformation was corrected by open abdominal surgery. For the procedure, pelvic adhesions were first isolated, after which the closed uterine cavity and adenomyosis were resected. Subsequently, the left ovarian endometriosis cyst was resected and right tubal ligation was performed. After surgery, three injections of gonadotropin-releasing hormone A (GnRH-A) were administered, which lowered the patient's CA125 level to 14 U/mL and normalized her condition.

CONCLUSION

We pioneered a new therapeutic approach for the treatment of Robert's uterus with adenomyosis. Some valuable references are provided for clinical practice.

Diagnosis and treatment of Robert's uterus combined with transverse uterine septum: a case report and review of the literature

Background

Robert's uterus combined with transverse uterine septum is a rare uterine malformation. Only one case has been reported to date, and it is challenging to diagnose and treat.

Case presentation

Here we report the case of a 19-year-old female had undergone multiple treatments at a previous hospital for primary amenorrhea and periodic lower abdominal pain, with the cause remaining unclear. Ultrasonography and magnetic resonance imaging conducted at our hospital displayed the presence of uterine dysplasia with an incomplete septum. Following a multidisciplinary discussion, a preliminary diagnosis of Robert's uterus combined with transverse uterine septum was made. Following this, laparoscopic exploration and ultrasound-guided hysteroscopic metroplasty were performed. The patient experienced periodic menstruation postoperatively and did not manifest periodic lower abdominal pain.

Conclusion

Robert's uterus combined with transverse uterine septum is a very rare uterine malformation, with hysteroscopic metroplasty being the preferred surgical option. Nevertheless, preoperative diagnosis is extremely difficult, and there are also many difficulties in the surgical process. This case outlines the diagnostic and treatment process of a patient with Robert's uterus and transverse uterine septum. It is of great significance to fill the gap in clinical diagnosis and treatment of this special uterine malformation.

Challenges in the diagnosis and management of Robert's uterus: Systematic review and case presentation

Robert's uterus is a rare Müllerian duct anomaly (MDA) characterized by complete asymmetric septum dividing uterine cavity into two non-communicating parts. This study offers insights into diagnosing and management of this condition in a young patient, and a systematic literature review. The review included 19 studies from 2013 to 2023. 11.4% of women reported a history of miscarriage and 5.7% primary infertility. Dysmenorrhea was the most frequent symptom (54.3%), and 14.3% of patients had a coexisting endometriosis. The surgical interventions most commonly combine laparoscopic and hysteroscopic techniques. Robert's uterus requires heightened clinical awareness for early diagnosis, particularly in young women.

Successful pregnancy in the blind hemicavity of Robert's uterus: a rare case report and brief literature review

BACKGROUND

Robert's uterus is a rare congenital anomaly, characterized as an asymmetric septate uterus that has a blind hemicavity with unilateral menstrual fluid retention and a unicornuate hemicavity connecting to the cervix unimpededly. Patients with Robert's uterus generally present with menstrual disorders and dysmenorrhea, and some may have reproductive problems as well, including infertility, recurrent miscarriage, preterm labor and obstetric complications. In this case, we describe a successful pregnancy implanted on the obstructed hemicavity and delivered a liveborn girl. Meanwhile, we highlight diagnostic and therapeutic difficulties in patients with atypical symptoms of Robert's uterus.

CASE PRESENTATION

A 30-year-old Chinese primigravida sought for emergency treatment at 26 weeks and 2 days of gestation because of preterm premature rupture of membranes (PPROM). At the age of 19, the patient was misdiagnosed with hyperprolactinemia and pituitary microadenoma for showing symptom of hypomenorrhea and was suspected to have a uterine septum in the first trimester. She was diagnosed with Robert's uterus at 22 weeks of gestation by repetitious prenatal transvaginal ultrasonography, which was subsequently confirmed by magnetic resonance imaging. At 26 weeks and 3 days of gestation, the patient was suspected to have oligohydramnion, irregular uterine contraction, and umbilical cord prolapse, and she expressed a strong will of saving the baby. Emergency cesarean delivery was performed and a small hole, together with several weak spots, was found at the lower and back wall of the septum of the patient. The treatment was effective and both the mother and the infant, who had an extremely low birth weight, were discharged in good health conditions.

CONCLUSIONS

Pregnancy in the blind cavity of Robert's uterus with living neonates is incredibly rare. In our case, the favorable outcome may result from the unusual hole found at the septum, which may play a role in communicating amniotic fluid between the two hemicavities so to keep the neonate alive. we highlight the importance of early diagnosis and pre-pregnancy treatment of this uterine malformation, and the timely termination of pregnancy, for improving birth quality and reducing mortality.

Robert's Uterus versus Juvenile Cystic Adenomyoma - Diagnostic and Therapeutic Challenges - Case Report and Review of Literature

This case report highlights the diagnostic dilemma and therapeutic challenges encountered while managing adolescent girls with progressive dysmenorrhoea and management of Robert's uterus. Two girls aged 20 years and 13 years presented with severe progressive dysmenorrhoea. In the first case, laparoscopy revealed juvenile cystic adenomyoma (JCA) of 3 cm × 3 cm on the left side anteroinferior to the round ligament. Laparoscopic resection of the lesion was done, and histopathology revealed features of adenomyosis. In the second case, there was a globular enlargement of the right half of the uterine body with round ligament and adnexa attached to the lesion (Robert's uterus). In view of severe symptoms, complete resection of the lesion and partial resection of hemi-uterus was done, followed by myometrial defect closure. Both cases were initially diagnosed as JCA, and the final diagnosis was made on laparoscopy. Both girls had complete symptomatic relief from the next menstrual cycle and have been under follow-up for 24 months and 18 months, respectively. Due to the rarity of conditions, Robert's uterus and JCA are usually misdiagnosed with each other or with other Mullerian anomalies such as a non-communicating unicornuate uterus. Radiologists and clinicians should be aware of these different pathologies causing similar symptoms. Understanding the pathology, early diagnosis, timely referral and correct surgical procedure are emphasised to improve reproductive outcomes.

Role of Laparoscopic Transillumination Guidance During Hysteroscopic Metroplasty in Simplifying Surgical Management of Type II Robert's Uterus

Robert's uterus is a rare variant of septate uterus with an asymmetrical septum which divides the uterine cavity into a noncommunicating hemiuterus causing hematometra and other communicating hemiuterus with a single cervix and a normal fundal contour (U2bC3V4 ESHRE classification). It is a cause of severe dysmenorrhea in young girls. However, there is a type of Robert uterus (Type II) which does not have collection in the blind cavity and causes symptoms later, similar to our case. We describe a case of hysteroscopic septum resection (metroplasty) with laparoscopic guidance by transillumination in a case of Type II Robert's uterus in a 25-year-old nulliparous woman. Thick muscular septum posed a surgical challenge which was supplemented by astutely utilizing laparoscopic transillumination.

Laparo-Endoscopic Single Site Combined With Hysteroscopy to Diagnose and Treat Robert’s Uterine Malformation: A Case Report

Asymmetric septate uterus, commonly known as Robert’s uterus, is an exceedingly rare uterine malformation described for the first time in 1970 by Robert H. Currently, surgery is the therapy of choice for Robert’s uterus, with surgical choices ranging from laparotomy to minimally invasive surgery. In this paper, we reported that a 14-year-old girl with primary dysmenorrhea that gradually worsened three months after menarche had surgery after many imaging evaluations, and that the intraoperative diagnosis was Robert’s uterus. The diagnostic and therapeutic laparo-endoscopic single site(LESS) combined with hysteroscopy surgery for Robert’s uterine abnormality was shown via a step-by-step presentation of the method accompanied by narrated video footage. During the ten-month postoperative follow-up period, the patient had monthly recurrences with normal menstrual volume and no dysmenorrhea, demonstrating that as a minimally invasive treatment, LESS combined with hysteroscopy surgery is a successful methodfor diagnosing and treating this specific malformation.

Robert's uterus (asymmetric septate uterus): a rare congenital Müllerian duct anomaly

Müllerian anomalies such as Robert's uterus, which was first described by the French gynaecologist Dr Helene Robert in 1969, are rare clinical entities and have been reported in <3% of the female population. Robert's uterus is a rare phenomenon with a relative dearth of reported cases. Affected individuals may present with pelvic pain and dysmenorrhoea that intensifies near menses or acutely, with severe abdominal pain to the emergency department. They are also associated with adverse pregnancy outcomes, abnormal fetal presentation, preterm labour, recurrent pregnancy loss and infertility. Although ultrasound has a role in its initial assessment, MRI is the best modality to further delineate its anatomy. It is typically managed via laparotomy and total horn resection, endometrectomy of the blind cavity or abdominal metroplasty. The authors present the case of a 40-year-old woman at 19+3 weeks gestation with acute onset of left-sided abdominal pain. A transvaginal ultrasound and MRI of the pelvis confirmed a Robert's uterus with a viable pregnancy in the upper left horn. She developed a ruptured horn with significant haemoperitoneum. An emergency laparotomy was performed and a non-viable fetus was evident. Only a few cases of pregnancy in the blind hemicavity have been reported so far. This case also highlights the importance of considering this diagnosis in young females presenting with dysmenorrhoea and normal menstrual flow. It is imperative to render a prompt diagnosis, as minimally invasive procedures may be more effective if detected before the formation of adnexal endometriomas.

Intrauterine adhesions combined with Robert's uterus: a case report and literature review

PURPOSE

To summarize the clinical characteristics and surgical option of Robert's uterus.

METHODS

We reported a rare case of Robert's uterus with severe uterine adhesion with successive laparoscopic and hysteroscopic surgery. To our knowledge, such a case has not been reported previously. We also performed a systematic literature review from the PubMed, Embase, and Cochrane databases.

RESULTS

Our patient with Robert's uterus with severe uterine adhesions was successfully treated with hysteroscopic septal resection and hysteroscopic adhesiolysis, and the intractable dysmenorrhea disappeared after the hysteroscopic septal resection. In our study, we analyzed the selected 22 reported cases, 10/22 cases (45.5%) were diagnosed before age 20; 20/22 cases (90.91%) experienced dysmenorrhea, 19/22 cases (86.36%) were with hematometra. 5/22 cases (22.73%) underwent re-operation or a third surgery before diagnosis and management.

CONCLUSION

Robert's uterus, a rare congenital abnormality of Mullerian duct development, consists of an oblique septum and non-communicating asymmetrical uterine hemi-cavity. The main symptoms are the presence of hematometra and severe dysmenorrhea. Septal resection is the main surgical procedure; however, the rarity and difficulty obtaining a pre-operative diagnosis lead to a high rate of misdiagnosis and second surgery.

Robert's Uterus-Rare Cause of Intractable Dysmenorrhea and Chronic Pelvic Pain

Robert's uterus is a rare type of congenital uterine anomaly where septum divides the uterine cavity asymmetrically resulting in the formation of a noncommunicating hemiuterus. Patients may present with recurrent pain, dysmenorrhea, recurrent abortions, and infertility. They are often misdiagnosed as unicornuate uterus with a noncommunicating horn. Thirty-year nulliparous female with history of severe dysmenorrhea since her menarche for which she had been operated thrice with no relief, presented with severe abdominal pain. Magnetic resonance imaging findings were suggestive of possibility of accessory horn with left hematosalpinx and hemorrhagic fluid in pelvis. Intraoperatively, it was found to be thick uterine septum completely dividing the uterine cavity asymmetrically with no communication with cervix indicative of Robert's uterus.

Hysterosalpingo-Foam Sonography for the Diagnosis of Tubal Occlusion: A Systematic Review and Meta-analysis

This systematic review and meta-analysis evaluated the diagnostic accuracy of hysterosalpingo-foam sonography in suspected cases of tubal occlusion. The combined sensitivity and specificity estimates were 0.99 (95% confidence interval [CI], 0.89-0.99) and 0.91 (95% CI, 0.53-0.98), respectively, with positive and negative likelihood ratios of 11.5 (95% CI, 1.5-87.5) and 0.006 (95% CI, 0.0003-0.12), respectively. The diagnostic odds ratio was 1931.008 (95% CI, 69.7-53,460.8). These findings confirm hysterosalpingo-foam sonography as a highly accurate test for the diagnosis of tubal occlusion and show that it is on a par with standard tests.

Imaging features of Robert's uterus: Case series of a rare Mullerian duct anomaly

The diagnosis of Mullerian duct anomaly is crucial because of strong association with infertility, endometriosis and miscarriage. Robert's uterus is a rare variant of septate uterus. Patients present with recurrent abdominal pain and severe dysmenorrhoea. Magnetic resonance imaging is the investigation of choice. In this case series, we present the imaging features of four such cases.

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.

Robert's uterus with delayed diagnosis and potential consequences: a case report

A 24-year-old woman who wished to become pregnant presented to our hospital with an enlarged ovarian endometrioma and developmental abnormality of the uterus. Robert’s uterus complicated by hematosalpinx, ovarian endometrioma, and endometriosis were finally identified 1 year after previously being diagnosed with a cyst and uterine abnormality at a local hospital. The function of the salpinx and the pelvic environment were damaged because of the delayed diagnosis and operation. Gynecologists and sonologists should be aware of and alert to this rare entity while evaluating and managing cases of uterine abnormalities and endometriosis. Prompt early diagnosis and proper management of Robert’s uterus are important for avoiding future morbidity because these are major factors in protecting fertility.

Critical Role of 3D ultrasound in the diagnosis and management of Robert's uterus: a single-centre case series and a review

A septate uterus with a non-communicating hemicavity was first described by Robert in 1969/70 as a specific malformation of the uterus. The condition is commonly associated with a blind uterine hemicavity, unilateral haematometra, a contralateral unicornuate uterine cavity and a normal external uterine fundus. The main symptoms are repetitive attacks of pain at four-weekly intervals around menarche, repeated dysmenorrhea, recurrent pregnancy loss and infertility. In this report, we review the disease, its diagnosis and treatment, and describe five cases of Robert's uterus. Three dimensional (3D) ultrasound (US) imaging was performed by the transvaginal route in four cases. In the fifth case of a 13-year-old girl, we avoided the vaginal route and magnetic resonance imaging (MRI) and 3D transrectal US yielded the correct diagnosis. The following treatment procedures were undertaken: laparoscopic endometrectomy, hysteroscopic septum resection, laparoscopic uterine hemicavity resection and total laparoscopic hysterectomy (TLH). The diagnosis and optimum treatment of Robert's uterus remains difficult for clinicians because of its rarity. A detailed and careful assessment by 3D US should be performed, followed by hysteroscopy in combination with laparoscopy, to confirm the diagnosis.

Analgesic Efficacy of Intrauterine Lidocaine Flushing in Hysterosalpingo-foam Sonography: A Double-blind Randomized Controlled Trial

STUDY OBJECTIVE

To evaluate the efficacy of flushing the uterine cavity with lidocaine before hysterosalpingo-foam sonography (HyFoSy) to reduce procedure-related pain.

DESIGN

A double-blind randomized controlled trial was conducted at the Department of Obstetrics and Gynecology, Shamir Medical Center, Israel between June 2020 and September 2020 involving 80 women undergoing a HyFoSy procedure.

SETTING

University-affiliated medical center.

PATIENTS

A total of 40 women were assigned randomly to the lidocaine group and 40 to the saline (placebo) group using a predetermined randomization code. Intrauterine instillation before the procedure consisting of either lidocaine 2% or normal saline alone was conducted, respectively.

INTERVENTIONS

The primary outcome measure was the visual analog scale (VAS) pain score during the phase of intrauterine foam instillation reported by the women after the procedure. The VAS consisted of a 10-cm line ranging from 0 to 10 (anchored by 0 = no pain and 10 = very severe pain). On the basis of the VAS scores, the pain level ratings were classified as mild (rated 1-3), moderate (4-6), or severe (7-10).

MEASUREMENTS AND MAIN RESULTS

The patient characteristics and obstetric data were found to be similar in both groups. Comparison of the VAS pain scores experienced during the procedure showed that women in the lidocaine flushing group rated the procedure less painful than the women in the saline group (3.0 ± 1.3 vs 6.3 ± 1.5, respectively; p = .001). The incidence of severe pain was significantly lower in the lidocaine group than the saline group (2.5% and 45.0%, respectively, p = .001).

CONCLUSION

Lidocaine flushing of the uterine cavity before HyFoSy significantly decreased the pain known to be caused by this procedure and had the advantage of no side effects. It is easily applied, relatively inexpensive, and may affect compliance with this procedure.

Unicornuate uterus with noncommunicating functional horn: diagnostic workup and laparoscopic horn amputation

OBJECTIVE

To describe the diagnosis and the management of hematometra in a patient with unicornuate uterus with noncommunicating functional horn (hemi uterus and rudimentary uterine hemicavity).

DESIGN

Video case report.

SETTING

Minimally invasive gynaecology unit.

PATIENT(S)

Sixteen-year-old nulliparous woman admitted to the gynaecologic emergency department with pelvic pain during menses.

INTERVENTION(S)

Two-dimensional transvaginal ultrasound, magnetic resonance imaging, and laparoscopic rudimentary horn resection.

MAIN OUTCOME MEASURE(S)

Description of a case of anomaly of the female reproductive tract treated by laparoscopy.

RESULT(S)

After pain reduction and stabilization of clinical condition, ultrasound and magnetic resonance were performed, which detected a hemi uterus with a right rudimentary uterine hemicavity and a hematosalpinx. The removal of the right rudimentary uterine horn was successfully performed. The patient was in good health at the 3-month follow-up visit.

CONCLUSION(S)

Laparoscopic amputation of a functional rudimentary horn is considered the basic and traditional surgical option for women with hemiuterus. A detailed diagnostic evaluation should be performed to avoid misdiagnoses of other anomalies with blind hemicavity, which may be treated by hysteroscopy. Laparoscopic surgery with minimally invasive approach could be an essential tool to treat these cases, achieving optimal results with low postsurgical pain and a short hospital stay.

Pregnancy in a blind hemi-cavity of Robert's uterus with ipsilateral renal agenesis: a case report and literature review

Robert’s uterus is an asymmetric septate uterus with a noncommunicating cavity and is a rare Müllerian anomaly. We present a rare case of pregnancy in a blind cavity and the first report of ipsilateral renal agenesis. A 23-year-old primigravida woman presented to our hospital at 7 weeks and 3 days of gestation after an abortion had failed. Three-dimensional ultrasound and magnetic resonance imaging showed pregnancy in a blind hemi-cavity of Robert’s uterus with an ipsilateral renal anomaly. Surgery was performed by hysteroscopy with laparoscopic and ultrasound guidance. The pregnancy was removed and the asymmetric septum was resected. A single normal uterine cavity with bilateral tubal ostium remained. The treatment was considered to be satisfactory. Menstruation ceased to be painful and the uterus was not scarred. Robert’s uterus can be well evaluated by an experienced ultrasound physician and magnetic resonance imaging. Such patients may have renal agenesis and the urinary system must be simultaneously evaluated. Pregnancy in a blind hemi-cavity is extremely rare and easily ignored by gynecologists and sonographers. Timely and accurate diagnosis of this condition is essential to obtain minimally invasive treatment.

Congenital Uterine Malformation by Experts (CUME): better criteria for distinguishing between normal/arcuate and septate uterus?

OBJECTIVES

To assess the level of agreement between experts in distinguishing between septate and normal/arcuate uterus using their subjective judgment when reviewing the coronal view of the uterus from three-dimensional ultrasound. Another aim was to determine the interobserver reliability and diagnostic test accuracy of three measurements suggested by recent guidelines, using as reference standard the decision made most often by experts (Congenital Uterine Malformation by Experts (CUME)).

METHODS

Images of the coronal plane of the uterus from 100 women with suspected fundal internal indentation were anonymized and provided to 15 experts (five clinicians, five surgeons and five sonologists). They were instructed to indicate whether they believed the uterus to be normal/arcuate (defined as normal uterine morphology or not clinically relevant degree of distortion caused by internal indentation) or septate (clinically relevant degree of distortion caused by internal indentation). Two other observers independently measured indentation depth, indentation angle and indentation-to-wall-thickness (I:WT) ratio. The agreement between experts was assessed using kappa, the interobserver reliability was assessed using the concordance correlation coefficient (CCC), the diagnostic test accuracy was assessed using the area under the receiver-operating characteristics curve (AUC) and the best cut-off value was assessed using Youden's index, considering as the reference standard the choice made most often by the experts (CUME).

RESULTS

There was good agreement between all experts (kappa, 0.62). There were 18 septate and 82 normal/arcuate uteri according to CUME; European Society of Human Reproduction and Embryology (ESHRE)-European Society for Gynaecological Endoscopy (ESGE) criteria (I:WT ratio > 50%) defined 80 septate and 20 normal/arcuate uteri, while American Society for Reproductive Medicine (ASRM) criteria defined five septate (depth > 15 mm and angle < 90°), 82 normal/arcuate (depth < 10 mm and angle > 90°) and 13 uteri that could not be classified (referred to as the gray-zone). The agreement between ESHRE-ESGE and CUME was 38% (kappa, 0.1); the agreement between ASRM criteria and CUME for septate was 87% (kappa, 0.39), and considering both septate and gray-zone as septate, the agreement was 98% (kappa, 0.93). Among the three measurements, the interobserver reproducibility of indentation depth (CCC, 0.99; 95% CI, 0.98-0.99) was better than both indentation angle (CCC, 0.96; 95% CI, 0.94-0.97) and I:WT ratio (CCC, 0.92; 95% CI, 0.90-0.94). The diagnostic test accuracy of these three measurements using CUME as reference standard was very good, with AUC between 0.96 and 1.00. The best cut-off values for these measurements to define septate uterus were: indentation depth ≥ 10 mm, indentation angle < 140° and I:WT ratio > 110% .

CONCLUSIONS

The suggested ESHRE-ESGE cut-off value overestimates the prevalence of septate uterus while that of ASRM underestimates this prevalence, leaving in the gray-zone most of the uteri that experts considered as septate. We recommend considering indentation depth ≥ 10 mm as septate, since the measurement is simple and reliable and this criterion is in agreement with expert opinion. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Magnetic Resonance Imaging (MRI) Depiction of Robert's Uterus: A Rare Müllerian Duct Anomaly Presenting with Cyclical Pain in Young Menstruating Woman

Background

Robert’s uterus is a very rare müllerian duct anomaly which is characterised by septate uterus with obstruction of a one-sided cavity and formation of hematometra. Therefore, patients present with cyclical abdominal pain during menstruation along with normal menstrual flow.

Case Report

We present magnetic resonance imaging (MRI) findings in a case of Robert’s uterus in a young woman.

Conclusions

Robert’s uterus is a very rare anomaly which can be very well characterized by magnetic resonance imaging (MRI). MRI can also show any associated hematometra and endometriomas complicating this condition and aid in the institution of appropriate management in such cases.

Assessment of the uterus with three-dimensional ultrasound in women undergoing ART

BACKGROUND

A detailed assessment of the uterus forms a pivotal part of the ART treatment process. The emergence of three-dimensional ultrasound (3D US) has provided clinicians with a highly powerful tool in this respect. Assessments with 3D US range from the reconstruction of anatomical planes elusive to conventional US, to the objective measurement of anatomical volumes and vascularization parameters. However, despite the ever increasing number of publications emerging in the literature, the question of which aspects of 3D US are of most clinical value remains a topic of debate.

OBJECTIVE AND RATIONALE

The objective of this review is to dissect which aspects of the 3D US assessment of the uterus are supported by a strong level of evidence to date, and should therefore be incorporated into current routine clinical practice.

SEARCH METHODS

We conducted a systematic search of the PubMed database up to May 2016, using a combination of text words and Medical Subject Headings (MeSH) pertaining to the 3D US assessment of the uterus. All articles published in the English language were screened to ascertain relevance to women of reproductive age; further citations were retrieved through manual reference list searching.

OUTCOMES

A multitude of predominantly observational studies were identified, which concerned a vast variety of 3D US uterine assessments. All articles unequivocally praised the non-invasive, cost-effective, highly acceptable and objective nature of 3D US. Studies regarding the value of assessing the endometrial volume and vascularization prior to embryo transfer appeared conflicting and inconsistent. Studies regarding the imaging of uterine pathology and identification of intratubal and intrauterine devices consistently reported high rates of diagnostic accuracy. A recent RCT did not show an improvement in clinical outcomes when comparing 3D versus 2D US during embryo transfer. However, preliminary studies suggested that 3D US is superior in determining the site of implantation, particularly in ambiguous cases such as interstitial and angular pregnancies. Finally, pilot studies have suggested that the further integration of 3D and possibly 4D US with surgical interventions of the uterus may be a promising prospect.

WIDER IMPLICATIONS

3D US may prove to be an invaluable tool in the assessment of the uterus within the context of ART. Currently, the aim should be to highlight the aspects of 3D US that are most evidence-based and valuable for patients, and to incorporate these into routine clinical practice.