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Navigating Complexity: Advanced Visualization for Müllerian Anomalies and its Implications for Diagnoses and Surgical
Anat From1, Tania Dumont1, Sukhbir Singh2
1Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario, Canada; Department of Surgery, CHEO, Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
Background:
Obstructive Müllerian anomalies present diagnostic and surgical-planning challenges, often requiring multiple imaging studies and prolonged medical management. Three-dimensional (3-D) modelling and virtual-reality (VR) visualization may improve anatomic understanding, counselling, and operative safety.
Case:
A patient first evaluated at 15 years of age for primary amenorrhoea and cyclic pain underwent 8 MRIs and 6 ultrasounds over 7 years. Imaging progressively clarified complete proximal vaginal agenesis, a left unicornuate uterus with functioning endometrium, a non-communicating right rudimentary horn, bilateral hydrosalpinges, and, ultimately, obstructive haematometra. Despite sequential hormonal suppression (combined oral contraceptives, depot-medroxyprogesterone acetate, dienogest, norethindrone acetate) and vaginal dilation, pain recurred. Multidisciplinary consultations explored fertility-preserving reconstruction versus definitive surgery. At 23 years of age, severe acute pelvic pain, and a 12 cm haematometra led to admission.
Intervention:
High-resolution T2-weighted MRI obtained 1 week before surgery was segmented post-operatively with ElucisNext to create a patient-specific 3-D model. Definitive management, selected because of intractable pain and complex congenital heart disease (repaired double-outlet right ventricle with Glenn shunt), was total abdominal hysterectomy, left salpingo-oophorectomy, right salpingectomy, bilateral ureterolysis, adhesiolysis, and cystoscopy.
Outcomes:
VR review highlighted a blind cervix, absent proximal vagina, and ureters coursing in close proximity to the dilated horn. These findings underscored the prudence of prophylactic ureterolysis and illustrated anatomical barriers to creating a functional neovaginal-cervical connection. Although the model was constructed post-operatively, prospective use could have enhanced fertility counselling, guided earlier surgical decisions, and served as a rehearsal tool for trainees.
Conclusions:
Post-operative VR reconstruction of pre-operative MRI demonstrated tangible educational and planning value. Routine prospective VR adoption for complex Müllerian anomalies may optimize counselling, resident education, and surgical safety.
