(Video Poster 07) Minimally Invasive Approach to Megaureter with Concomitant Mullerian Anomalies

Objectives: The objective of this video is to demonstrate the diagnostic work-up and minimally-invasive surgical techniques for management of megaureter with concomitant mullerian anomalies.

Methods: This video describes a 37-year-old G1P0010 with complex Mullerian anomalies and unilateral renal agenesis who initially presented for infertility work-up and was diagnosed intraoperatively with megaureter secondary to stage IV endometriosis. Her initial work-up included saline infusion sonography (SIS) and magnetic resonance imaging (MRI) for surgical planning. Preoperatively, she was suspected to have obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome with a uterine didelphys and a right large hydrosalpinx. However, hysteroscopic and laparoscopic evaluation ultimately revealed a combined bicornuate septate uterus with a single cervix and partial obstruction of the right uterine cavity and a non-connecting megaureter filled with endometriotic fluid.

Clinical Relevance: The differential for tubular cystic adnexal masses often includes dilated pelvic veins, bowel loops, hydrosalpinx, ovarian cysts, and dilated ureters. Megaureter (MU) is a term used to describe an enlarged ureter that can be subdivided into congenital or secondary types. Most cases are congenital, diagnosed on antenatal ultrasonography, and can be managed with non-surgical approaches in children. MU is uncommon in adults, and current literature is limited primarily to case reports. Most cases described are limited to males presenting with recurrent urinary tract infections or flank pain. This video highlights endometriosis as a rare secondary cause of MU especially in patients with Mullerian and renal anomalies. It also demonstrates comprehensive evaluation and management of a complex Mullerian anomaly and provides an educational resource demonstrating key surgical steps for excision for similar cases.