Chronic pelvic pain can result from noncommunicating uterine cavities in patients with müllerian anomalies. Traditional management has been to resect the noncommunicating uterine horn. Two cases are described. One had a unicornuate uterus with noncommunicating left uterine horn (American Fertility Society [AFS] classification IIb) and the other had a normal external uterine contour with noncommunicating left uterine cavity that did not fit any category of the AFS classification of müllerian anomalies. Attempts at connecting the noncommunicating cavities hysteroscopically failed in both cases. Successful unification of the cavities was subsequently achieved in the first case using the classic Strassman metroplasty with the assistance of the robot. The unification of uterine cavities was achieved using a modified Strassman metroplasty in the second patient, as there was no uterine horn for landmark. Robot assistance was utilized in this case as well. Both patients are symptom free after surgery. We conclude that laparoscopic Strassman metroplasty, with or without robot assistance, is a viable alternative to resection of uterine horns in patients with hematometra, chronic pelvic pain, and noncommunicating uterine cavities.
Problem: Chronic pelvic pain secondary to müllerian anomalies that is unresponsive to medical therapy
Patient 1 was a 16-year-old G0 African American girl with a history of chronic pelvic pain. Pelvic imaging demonstrated a unicornuate uterus with an enlarged left hematometra (American Fertility Society [AFS] classification IIb) ( Figure 1 , A). With marginal pain relief on hormonal therapy, she was counseled about options of hysteroscopically connecting the left uterine horn to the right or resection of the left horn.
Patient 2 was a 21-year-old G0 Caucasian woman who presented with severe dysmenorrhea. She had left salpingo-oophorectomy at age 16 years and laparoscopic lysis of adhesions at age 20 years for chronic pelvic pain. Magnetic resonance imaging (MRI) revealed what appeared to be a noncommunicating left uterine cavity with hematometra, and a normal external contour of the fundus (no AFS classification) with a possible small conduit to the left uterine horn ( Figure 2 , A). The patient was initially offered medical suppression and hysteroscopic metroplasty.
In both cases, the patients had normal kidneys bilaterally, only 1 cervix was noted on speculum examination, and neither case had a vaginal septum. In patient 2, there was myometrium in the dividing wall.
Strassman metroplasty was described for management of habitual abortion and sterility in women with bicornuate uterus, although Strassman also suggested its use for severe dysmenorrhea and menometrorrhagia in those not responding to conservative treatment. Today, this procedure has fallen out of vogue, in favor of conservative management. Sporadic reports of Strassman metroplasty for management of hematometra, uterine adenomatoid tumor, and recurrent trophoblastic tumors have been published.
In both cases, a substantial left uterine cavity could be visualized on MRI and it was believed that unifying the cavities might afford a better reproductive outcome than removing it based on the same principles applied by Strassman. However, neither of these patients had the chance to trial their reproductive outcome before deciding to unify as in prior reported cases of Strassman metroplasty. We report Strassman metroplasty and modified Strassman metroplasty using a robot-assisted laparoscopic approach for the successful management of the above cases.
Our Solution
Patient 1
While it can be argued that hysteroscopy could be obviated in cases where there is an unequivocal noncommunicating horn, in this case, hysteroscopy was attempted with the belief that there was a small channel to the left uterine cavity. Instead, it revealed easy entry into the right uterine horn without an obvious opening to the left horn. The procedure was terminated. She and her family subsequently consented for a robot-assisted laparoscopic Strassman metroplasty to unify the cavities for symptom relief. A robotic approach was utilized to take advantage of the highly magnified, 3-dimensional view and easier suturing and knot tying, although a traditional laparoscopic approach can also be taken. At surgery, vasopressin was infiltrated subserosally along the medial aspect of both uterine horns, and an incision was made through the myometrium on the medial side of both uterine horns about 2 cm from the fallopian tube and inferiorly toward the base of each horn.
After decompressing the left horn, the opposing myometrial edges were sutured with interrupted 2-0 polyglactin 910 sutures with caution to avoid the endometrium. The serosa was closed using a running 4-0 polyglactin 910 suture and Interceed (Ethicon Inc., Cincinatti, OH) was placed ( Video 1 ). Postoperative sonogram demonstrated resolution of the hematometra and the patient is pain free on continuous hormone therapy ( Figure 1 , B). While it is possible that the unified portion may have scarred over and reoccluded, it is unlikely as there was normal endometrium development in postoperative sonograms.
Patient 2
Under laparoscopic ultrasound guidance, hysteroscopy revealed entry into the right side of the uterus, but no connection to the left. Laparoscopically, a bulge to the left midline on the uterine fundus was discerned. Hysteroscopic unification was attempted using resection. Technical difficulties included absence of landmarks hysteroscopically and air bubbles obscuring ultrasound visualization. An inadvertent posterior wall perforation of the right uterine cavity was encountered. Two technically challenging options were considered: (1) resection of the left uterine body, and (2) performing a modified Strassman metroplasty. We elected to perform a modified Strassman metroplasty using the robot ( Video 2 ).
An incision was made over the left side of fundus using laparoscopic ultrasound guidance, inserted through a 10-mm port, to gain entry into the left uterine cavity, followed by extension to the right side using the perforation as a guide. Dissection of the medial wall was carried down to the lower uterine segment. A balloon uterine stent was positioned straddling both uterine cavities and left in place. Using the stent for orientation, the submucosal, myometrial, and serosal layers were reapproximated using 3-0 V-Loc suture (Medtronic Inc., Minneapolis, MN). The stent was removed on postoperative day 7. With subsequent menses, she reported minimal discomfort. Hysterosalpingogram confirmed unified cavities and right tubal patency ( Figure 2 , B).
Based on our experience with these 2 cases, we recommend that hysteroscopic unification should not be attempted, although based on MRI images it may be tempting to consider. Unification, regardless of the approach, should not be attempted in the asymptomatic patient nor in those where there is no hematometra. That said, without data it is difficult to quantify the size of the noncommunicating horn, which should be considered for unification, although one may intervene with any increase in size. Concerns regarding the potential risk of rupture is something to consider, although it is unlikely; as seen with myomectomy with extensive scars on the uterus, the subsequent risk of uterine rupture after repair has been reported to be low.
Supplementary Data
Strassman metroplasty in patient 1 with unicornuate uterus with left hematometra.
Video 2Modified Strassman metroplasty for patient 2 with left hematometra and normal external contour of uterine fundus.
Dr Bhagavath is a paid consultant for Hologic.
Cite this article as: Bhagavath B, Behrman E, Salari BW, et al. Metroplasty to treat chronic pelvic pain resulting from outflow tract müllerian anomalies . Am J Obstet Gynecol 2015;213;871.e1-3.
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