Robert’s uterus is a rare congenital abnormality, a uterine septum asymmetrically separates the uterine cavity from the bottom of the uterus, half of which is a disconnected blind cavity [1]. Gupta et al. suggested that right side are common for the ahead advancement of left Mullerian duct [2]. However, blind cavity is more commonly left-side in the review. Musset et al [3] have summarized its characteristics include: (1) primary dysmenorrhea; (2) no significant difference of the uterus by laparoscopy and the unicorn uterine cavity found by hysterography; (3) no deformity of the urinary system. Most patients complained of dysmenorrhea, periodic abdominal pain, abnormal menstruation, abortion, or infertility. Twenty-two cases were conducted in our systematic reviewed literature (Table 1), 20/22 cases (81.82%) underwent dysmenorrhea [2, 4–19], 3/22 cases (13.64%) abortion [4, 7, 20], one case endured infertility [14]. It is noted that intractable dysmenorrhea seems to associate with haematometra for the identical existence. Gupta, N proposed that endometriosis may associate with menstrual blood reflux [2]. With hormonal stimulation, menstrual blood induced by the shedding of endometrium could be retrograde into the abdominal cavity through the ipsilateral fallopian tube during menstruation, thus the early dysmenorrhea was periodic but not obvious in initial. Then, with the right fallopian tube gradually thickened, blocked and blood accumulated, dysmenorrhea gradually aggravated due to the formation of a closed cavity, which may associate with inflammation or endometriosis. In our reported case, after the resection of the right fallopian tube, the blind cavity was completely disconnected from the outside world. As a result, increased pressure was associated with the retention of menstrual blood in the closed right-sided uterine cavity, which induced aggravated abdominal pain.
Table 1
Review of Robert’s uterus cases reports.
Authors (year) | Case | Age (years) | Dysmenorrhea | Other complaints | Haematometra | Other complication |
Deenadayal. 2021 | five | 28.2(M) | Yes(5/5) | Recurrent abortion(1/5) | Yes(4/4) | Adenomyosis(2/4), Endometrioma(2/4) |
Zhang J. 2021 | one | 24 | Yes | - | Yes | Hematosalpinx, Endometriosis |
Liu Y. 2021 | one | 45 | No | abnormal menstruation | No | Blind hemicavity Pregnancy, Adenomyosis |
Liu Y. 2020 | one | 16 | Yes | Acute abdominal pain | Yes | Ipsilateral renal agenesis, Hematosalpinx |
Yang QM. 2019 | one | 23 | Yes | Abortion | Yes | Blind cavity pregnancy, Ipsilateral renal agenesis, Adenomyosis |
Shah N. 2019 | 1 | 16 | Yes | - | Yes | - |
Kiyak H. 2018 | one | 15 | Yes | - | Yes | - |
Biler A. 2017 | one | 29 | Yes | mild abdominal pain, abnormal menstruation | Yes | - |
Mittal P. 2017 | one | 15 | Yes | - | Yes | Haematosalpinx, Endometriosis |
John SK. 2017 | one | 16 | Yes | Acute abdominal pain | Yes | - |
Ludwin A. 2016 | one | 22 | Yes | - | Yes | - |
Di Spiezio Sardo A. 2015 | one | 30 | Yes | infertility | Yes | Uterine myomas, A pseudocystic lesion |
Li J. 2015 | one | 26 | Yes | - | Yes | Ovarian endometriotic cyst, Endometriosis |
MaddukuriSB.2014 | one | 16 | Yes | - | Yes | Haematosalpinx |
Vural M. 2011 | one | 24 | Yes | - | Yes | - |
Capito C. 2009 | one | 15 | Yes | Acute abdominal pain | Yes | - |
Gupta N. 2007 | one | 19 | Yes | Acute abdominal pain | Yes | Ovarian endometriotic cyst, Endometriosis |
Singhal S. 2002 | one | 20 | No | Abortion | No | Blind cavity pregnancy |
To the best of our knowledge, Intrauterine adhesions are first involved in Robert's uterus which have been verified by the laparoscopy, although no intrauterine operation history such as induced abortion, which may be related to obstruction of menstrual blood outflow and inflammation, although there is no evidence of endometritis. In our opinion, early diagnosis and hysteroscopic surgery may reduce incidence of these complication. Ultrasound, MRI, hysteroscopy, and laparoscopy have been performed for Robert’ uterus diagnosis. The septum with asymmetric cavities is easily discernible, hematometra and hematosalpinx are easy to identify by the noninvasive imaging modalities, such as 3D-US and MRI, Which are considered the reliable modality to examine the morphology of the uterus [14, 21]. In addition, we strongly recommended a detailed inspection of urinary system considering that two cases of ipsilateral renal agenesis were reported. Ludwin et al. described three types of Robert’s uterus according to the amount of bleeding in the blind cavity: no hematocele, small and large [19]. However, the detection rate of uterine malformation by ultrasound is also significantly affected by the diagnostic level of the examiner. In the literature, 5/22 cases (22.73%) endured re-operation or the third time surgery before diagnosis and management [2, 4, 5, 6, 12]. It is still a challenge for clinicians, especially the differentiation of serious dysmenorrhea of Robert's uterus and other acute abdominal diseases. we recommend that if the intraoperative finding is inconsistent to clinical manifestation of severe abdominal pain, uterine inspection is needed. Trauma would be relatively less if taking adequate evaluation and determining the preoperative diagnosis.
Surgical treatment is recommended as soon as it is highly suspected. Surgical option may determine by the factors of age and fertility desire of patient. The prime targets are drainage of hematometra and prevention of its recurrence through septal resection [11]. Laparoscopic septum resection and metroplasty seems to be considerable for the minimal invasion, especially for the adolescent girl. In twenty-one cases of Robert's uterus involved surgery (Table 2), 13/21 cases (61.90%) were performed septal resection by laparoscopy, hysteroscopy or laparotomy. 11/21 cases (52.38%) of endometriosis have been documented in patients performed laparoscopy or hysteroscopy [7, 8, 10, 11, 13, 14]. There is prevalence in laparoscopy-guided hysteroscopic metroplasty recently for the advantage of security and less invasion, one case underwent hysterectomy due to no fertility requirement. Hysteroscopic surgery performed by experienced surgeons is essential for the complicated environment in uterus. At present, the main surgical methods reported in the literature are hysteroscopy or hysteroscopy combined with laparoscopic surgery [8, 10, 11]. Laparoscopy can deal with hematosalpinx, pelvic adhesions, and endometriosis, which cannot be evaluated by auxiliary examination. Some of the Robert's uterus have normal external uterine contour [12], making it difficult to identify in the laparoscopic surgery. Successful pregnancy and the cesarean section of healthy babies after ultrasound-monitored laparoscopy combined with hysteroscopy in patients with Robert's uterus have been reported [15]. If our patient has fertility requirements in the future, salpingography can be done first to determine whether the left fallopian tube is unobstructed, and then decide on natural pregnancy or assisted reproductive treatment. Monitoring the situation of pregnancy and appropriate intervention to achieve better pregnancy outcomes if required.
Table 2
Review of Robert’s uterus cases reports.
Authors (year) | Side | Main surgical Treatment | Number of operations |
Deenadayal. 2021 | Left (5/5) | Laparoscopic endometrectomy of the blind cavity (1/5), Hysteroscopic septal resection under laparoscopic control (1/5), Laparoscopic excision of the blind cavity (1/5), Hysterectomy with unilaeral salpingo- oophorectomy (1/5), No treatment (1/5) | one(3/4), three(1/4) |
Zhang J. 2021 | Right | Hysteroscopic septal resection and laparoscopic oophorectomy | one |
Liu Y. 2021 | Right | Hysterectomy and right salpingectomy | two |
Liu Y. 2020 | Right | Hysteroscopic septal resection and Laparoscopic right salpingectomy | two |
Yang QM. 2019 | Right | Hysteroscopic septal resection and Laparoscopy guidance | one |
Shah N. 2019 | Left | Hysteroscopic septal resection and Laparoscopy guidance | one |
Kiyak H. 2018 | Right | Laparoscopic septal resection | one |
Biler A. 2017 | Right | Hysteroscopic septal resection and Laparoscopy guidance | one |
Mittal P. 2017 | Left | Laparotomy excision of the blind cavity | one |
John SK. 2017 | Right | Laparotomy septal resection | three |
Ludwin A. 2016 | Left | Hysteroscopic septal resection. | one |
Di Spiezio Sardo A. 2015 | Left | Hysteroscopic septal resection and Laparoscopy guidance | one |
Li J. 2015 | Left | Laparotomy septal resection and laparoscopic oophorocystectomy | one |
MaddukuriSB.2014 | Left | Laparotomy septal resection | one |
Vural M. 2011 | Left | Laparotomy endometrectomy of the blind cavity | one |
Capito C. 2009 | - | Laparotomy endometrectomy of the blind cavity | one |
Gupta N. 2007 | Right | Laparotomy septal resection | two |
Singhal S. 2002 | Right | Laparotomy | one |
Robert's uterus is rare but can mimic other common acute abdominal disease. Adequate evaluation in each case is crucial for diagnosis and management.