A combined endoscopic and ultrasonographic approach to a complex U4a uterine anomaly.

Background: Uterine malformations are congenital anomalies arising from abnormal Müllerian duct development during embryogenesis. These can be linked to vaginal cysts, resulting in complex malformations. One rare form is the unicornuate uterus, where only one duct develops, leading to complications like severe pain due to a rudimentary, non-communicating horn.

Objectives: To describe a combined approach using ultrasound, hysteroscopy, and robotic-assisted laparoscopy for complex uterine anomalies.

Participant: A 30-year-old nulliparous woman with unilateral kidney agenesis and acute pelvic pain referred to our centre.

Intervention: 2D ultrasound suggested a complex malformation. 3D ultrasound and magnetic resonance imaging confirmed a U4a uterus. Hysteroscopy revealed a hemicavity with one tubal ostium. Robotic-assisted laparoscopy enabled right salpingectomy and removal of the rudimentary horn while preserving the ovary. Intraoperative ultrasonography guided the drainage of vaginal cysts. As a result, vaginal cysts were drained, and the rudimentary horn was removed with ovarian preservation. The patient was discharged without complications and spontaneously conceived a healthy pregnancy 8 months later.

Conclusions: Unicornuate uterus with non-communicating horn and renal agenesis is a rare condition. A combined approach using ultrasound, hysteroscopy, and robotic-assisted laparoscopy allows comprehensive evaluation and treatment.

What Is New?: This is the first reported case of simultaneous and synergistic use of hysteroscopy and robotic-assisted laparoscopy for complex genital malformations under ultrasonographic guidance.