Three degrees of separation: complete uterine and cervical septa

To review the diagnosis and management of 3 variations of incomplete müllerian duct fusion and reabsorption.

Narrated video delineating the surgical management of 3 müllerian anomalies; this video was deemed exempt from review by the institutional review board of the Mayo Clinic.

Tertiary care academic medical center.

This video focuses on 3 müllerian anomalies: complete septate uterus with a single septate cervix (septate uterus unicollis); complete septate uterus with duplicated cervix (septate uterus bicollis); and complete duplication of the uterus and cervix (uterine didelphys).

Magnetic resonance imaging (MRI), cervical septoplasty, operative hysteroscopy, and uterine septoplasty.

Several variations of uterine malformations exist. In our practice, we differentiate complete septate uteri as either unicollis or bicollis via MRI and vaginal examination. The bicollis presentation can be identified on MRI by the "lambda sign," which is seen as the 2 cervices that diverge as they enter the vagina. This is in comparison with the unicollis presentation when the single septate cervix can be traced with parallel lines as it enters the vagina. The circle method is described in this video to help distinguish between a single and duplicated cervix on examination.

The cervical and uterine septa were resected completely in the patient with a complete septate uterus unicollis. In contrast, the uterine septum was resected completely and the 2 cervical canals were not incised in the case of the complete septate uterus bicollis. Although uterine and cervical septa resection is controversial, our practice is to avoid the incision of the 2 cervical canals in cases that are more clearly consistent with a bicollis classification.

Müllerian anomalies represent a continuum of disorders caused by different degrees of disruption in embryogenesis. MRI with vaginal gel and vaginal examination are tools to help classify the anomaly and guide surgical management.