Objective

To demonstrate the advantage of using aqueous vaginal contrast and scheduled hematocolpos with magnetic resonance imaging (MRI) to improve the delineation of gynecologic anatomy and to recommend that this modality be considered in patients with complex müllerian anomalies.

Design

Video demonstration of MRI adjuncts to improve visualization of gynecologic anatomy.

Setting

Academic Hospital.

Patient(s)

A patient with obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) who presented for definitive surgical management.

Intervention(s)

OHVIRA is a unilateral obstructed müllerian anomaly that presents typically after menarche with progressively worsening dysmenorrhea caused by progressive distension of the obstructed hemivagina and uterine horn. The definitive treatment for this anomaly is resection of the unilateral obstruction. When the obstructed hemivagina is within close proximity to the patent hemivagina, vaginal septum resection should be performed to relieve the obstruction successfully. However, when the obstructed hemivagina and uterine horn are not adjacent to the patent hemivagina, a simple septum resection is not feasible and there is a high rate of restenosis if anastomosis is attempted. In this case, laparoscopic removal of the obstructed uterine horn, fallopian tube, cervix, and vagina should be considered as an alternative approach to resolving the obstruction.

A surgical approach can be recommended only once the surgeon has a clear understanding of the patient’s pelvic anatomy and the magnitude of the obstruction. In the presented case, a 17-year-old patient with OHVIRA presented for definitive surgical management. While on hormonal suppression, a pelvic MRI was performed that identified a uterus didelphys with a left hemiuterus and cervix communicating with a patent vagina. The right hemiuterus and cervix were measured 2.5 cm from the patent vagina. However, because of hormonal suppression, the vaginal cavity was decompressed, making it very difficult to discern the relationship between the two uteri and vaginas. To better determine whether vaginal septum resection to relieve the obstruction was feasible, norethindrone was discontinued to allow menstrual blood to fill the obstructed hemivagina followed by a subsequent pelvic MRI with aqueous vaginal contrast to fill the patent vagina with contrast gel to improve the visualization of the decompressed vaginal cavities.

Main Outcome Measure(s)

Advantage of aqueous vaginal contrast and scheduled hematocolpos with MRI to image pelvic anatomy in a patient with a complex müllerian anomaly to guide surgical decision-making.

Result(s)

The addition of vaginal aqueous contrast clearly delineated the course and caliber of the patent vagina and its relationship to the obstructed hemivagina, now filled with blood. The inferior margin was in closer proximity to the patent vagina, but with only a very narrow segment (<1 cm) adjacent to the patent vagina and the obstructed cervix was displaced superiorly, now measuring 3.5 cm above the patent vagina. Surgical management options were discussed with the patient, and given the superior location of the obstructed uterus and cervix with only a narrow border of the vagina in continuity with the patent vagina, the risk of postoperative stenosis after vaginal septum resection was determined to be too high.

The decision was made to proceed with a laparoscopic resection of the obstructed right side, and the patient underwent laparoscopic resection of the right hemiuterus, fallopian tube, cervix, and vagina. Intraoperatively, a survey of the pelvis again confirmed that the two vaginas were too far to reconnect safely without a high risk of stenosis. The patient recovered without complications postoperatively and her menses resumed without any pain.

Conclusion(s)

We highlight the use of two techniques to optimize MRI imaging of pelvic anatomy in a patient with a complex müllerian anomaly. First, the use of aqueous vaginal contrast with MRI is advantageous to clearly delineate the course and caliber of the patent vagina in patients with complex gynecologic anatomy. Second, cessation of hormonal suppression to allow menstruation to cause hematocolpos helped delineate the relationship between the obstructed vagina and patent vagina. In the presented case, these MRI adjuncts provided necessary detail that could not be appreciated with standard MRI to confirm that vaginal septum resection to preserve the right uterus would be too high a risk for postoperative stenosis in this patient. Aqueous vaginal contrast and scheduled hematocolpos should be considered as adjuncts to MRI when standard imaging modalities are unable to clearly describe the relationship between pelvic structures in cases of complex müllerian anomalies to help guide treatment recommendations.

中文翻译：

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水性阴道造影剂和计划的结肠造血术与磁共振成像以描绘复杂的苗勒管异常

客观的

证明使用房水阴道造影剂和预定的阴道采血结合磁共振成像 (MRI) 来改善妇科解剖结构的优势，并建议在患有复杂苗勒管异常的患者中考虑这种方式。

设计

用于改善妇科解剖可视化的 MRI 辅助设备的视频演示。

环境

学术医院。

耐心）

一名患有半阴道梗阻和同侧肾发育不全 (OHVIRA) 的患者，他提出了明确的手术治疗。

干预措施

OHVIRA 是一种单侧梗阻苗勒管异常，通常在初潮后出现，由梗阻的半阴道和子宫角进行性扩张引起的进行性恶化的痛经。这种异常的最终治疗是切除单侧阻塞。当阻塞的半阴道靠近未闭的半阴道时，应进行阴道隔膜切除术以成功解除阻塞。然而，当阻塞的半阴道和子宫角不与未闭的半阴道相邻时，单纯的纵隔切除是不可行的，如果尝试吻合，再狭窄率很高。在这种情况下，应考虑腹腔镜切除阻塞的子宫角、输卵管、子宫颈和阴道作为解决阻塞的替代方法。

只有在外科医生对患者的骨盆解剖结构和梗阻程度有清楚的了解后，才能推荐手术方法。在本病例中，一名 17 岁的 OHVIRA 患者接受了明确的手术治疗。在荷尔蒙抑制期间，进行了盆腔 MRI，发现子宫双侧子宫和左侧半子宫和子宫颈与未闭阴道相通。测量右侧半子宫和子宫颈距未闭阴道 2.5 厘米。然而，由于荷尔蒙抑制，阴道腔被减压，很难辨别两个子宫和阴道之间的关系。为了更好地确定阴道中隔切除以缓解梗阻是否可行，

主要观察指标）

房水阴道对比剂和 MRI 计划的阴道采血对患有复杂苗勒管异常的患者的骨盆解剖结构进行成像以指导手术决策的优势。

结果）

阴道水对比剂的添加清楚地描绘了通畅阴道的路线和口径以及它与阻塞的半阴道的关系，现在充满了血液。下缘更靠近未闭阴道，但只有非常狭窄的部分（<1 cm）与未闭阴道相邻，阻塞的子宫颈向上移位，现在测量在阴道未闭上方 3.5 cm。与患者讨论了手术治疗方案，鉴于阻塞的子宫和宫颈位置优越，阴道边缘狭窄，与未闭阴道相连，确定阴道中隔切除术后狭窄的风险过高.

决定对阻塞的右侧进行腹腔镜切除术，并对患者进行腹腔镜切除右半子宫、输卵管、子宫颈和阴道。术中，骨盆检查再次证实，两个阴道距离太远，无法安全重新连接，没有很高的狭窄风险。患者术后恢复无并发症，月经恢复无痛。

结论

我们重点介绍了使用两种技术来优化患有复杂苗勒管异常的患者的盆腔解剖结构的 MRI 成像。首先，在具有复杂妇科解剖结构的患者中，使用阴道水对比剂和 MRI 有助于清楚地描绘阴道未闭的过程和口径。其次，停止激素抑制以允许月经引起阴道出血有助于描述阴道阻塞和阴道通畅之间的关系。在本例中，这些 MRI 辅助手段提供了标准 MRI 无法理解的必要细节，以确认阴道隔膜切除术以保留右子宫对于该患者术后狭窄的风险过高。