3D Ultrasound in the Diagnosis and Management of Robert's Uterus

Abstract

The condition of a septate uterus with a non-communicating hemicavity was first described by Robert in 1969/70 as a specific malformation of the uterus [1, 2]. It is commonly associated with a blind uterine horn, unilateral hematometra, a contralateral unicornuate uterine cavity, and a normal external uterine fundus. The main symptoms are repetitive attacks of pain at 4-week intervals around menarche in young girls, repeated dysmenorrhea, recurrent pregnancy loss, and infertility. In the present report, we briefly review the disease, its diagnosis and treatment, and describe five cases of Robert's uterus. 3D ultrasound 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 3D transrectal ultrasound yielded the correct diagnosis. The patient had been experiencing incapacitating dysmenorrhea, which started 3 days after commencement of her menstrual cycle. Transabdominal and transrectal 3D ultrasound revealed a hematometra on the left side measuring 5 × 5 cm, a right horn with an endometrium of 10 mm, and a septum with a thickness >1.5 cm. An additional magnetic resonance imaging (MRI) was performed in one patient to confirm the diagnosis. The following treatment procedures were used: laparoscopic endometrectomy, hysteroscopic septum resection, laparoscopic uterine horn resection, and total laparoscopic hysterectomy (TLH). Robert's uterus is difficult to diagnose preoperatively and is often misdiagnosed. Diagnostic modalities may include ultrasound, hysterosalpingography (HSG) and MRI. Ultrasound sensitivity for diagnosis of Robert's uterus is not high and frequently misdiagnosed as unicornuate uterus with noncommunicating rudimentary horn, as our case one. While HSG is usually suspected unicornuate uteri, with a typical fusiform or “banana” shape on imaging and visualization of only one fallopian tube, unfortunately, septate uteri cannot be fully differentiated with HSG given the absence of external fundal imaging. MRI is the best modality to demonstrate the uterine septum, normal external fundal contour, hematometra and hematosalpinx, but is unfortunately expensive. In cases of Robert's uterus, the coronal T2W images of MRI are ideal for demonstrating the uterine septum dividing the endometrial cavity asymmetrically along with the blind ending cavity and hematometra. T1W images show the hematometra and hematosalpinx as bright fluid in the endometrial cavity and dilated fallopian tube