The Problem was raised how to handle an 15 year old,  with apparently a cystic ovarian endometriosis and an uterine malformation.  Our response was posted at the AAGL-ENDO-EXCHANGE Digest, listserv

Date:    Mon, 26 Oct 2009 18:39:01 -0400

From:    “Philippe R. Koninckx; Anastasia Ussia and Gruppo Italo Belga”

Subject: Presumed Endometriosis in a 15 year old

The relatively rare problem of an uterus didelphys with hematometra, absent  kidney, and ovarian cyst has been discussed for several days.
- assuming the diagnosis of uterus didelphys is correct, she should have closed  hemi-vagina (and a normal hemi-uterus). In this case an incision of this vaginal
septum will permit drainage. This will permit the eventually associated  endometriosis to regress (as we demonstrated in baboons) while the  associated pelvic inflammatory reaction due to retrograde menstruation will  decrease. The necessary septum resection can then be performed a few  months later, preferably together with a diagnostic laparoscopy to diagnose and treat eventually remaining endometriosis.
- In case of a non communicating uterine horn with active endometrium resection of this horn preferably after a period of GNRH to decrease pelvic inflammation is inevitable.
- concerning the ovarian cyst I would be prudent since this can be a  functional cyst or a cystic corpus luteum. This would be another reason to  give GnRH for a few months before a laparoscopy is done.

Reading the answers, some at least deserve an answer
- *”Possibly a presacral neurectomy if she can distinguish a uterine cramping component of her pain”* Presacral neurectomy can be discussed, but the  decision to do this based upon uterine cramping , especially is in young girls is  new to me  and I would be interested to hear if there is any evidence for this.
-“*When I’m excising endometriosis  in teenagers, I also take the apparently normal peritoneum from areas that are most commonly involved by endometriosis in older women: cul de sac,  uterosacral ligaments, and medial broad ligaments, as this seems important in preventing the formation of endometriosis in those areas in the future.”* Also for this I have not seen any evidence in the literature.  Until evidence will be presented -maybe I missed it - I will consider the resection of large areas of normal pelvic peritoneum a surgical mistake based upon a personal opinions. This concept of removing ‘normal peritoneum’  has been floating around for some time  and I would suggest a debate at AAGL discussing this together with the ‘limits of freedom ‘ to perform non-proven or accepted  interventions.

Conclusion and remarks : The uterus didelphys  is a rare but  well known pathology. If associated with a functionally rudimentary horn this horn has to be removed. If associated with a semi occluded vagina, with an hematometra, this should be drained, and the vaginal septum subsequently resected.  Unfortunately not that many gynaecologists have experience with this pathology.

What we consider unacceptable however is non-validated surgery. Even great surgeons should only do ‘validated’ procedures and avoid surgery based on personal opinion. In addition we want to stress the importance of videoregistration to document what really was done during surgery.
Philippe R. Koninckx and Anastasia Ussia
University of Leuven, Leuven, Belgium  and Gruppo Italo Belga, Rome Italy

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