A Rare Uterine Malformation: Asymmetric Septate Uterus Alper Biler, MD, Ali Akdemir, MD, Nuri Peker, MD, and Fatih Sendag, MD* From the Department of Obstetrics and Gynecology (Dr. Biler), Tepecik Training and Research Hospital, Izmir, Turkey, Department of Obstetrics and Gynecology (Drs. Akdemir and Sendag), Ege University School of Medicine, Izmir, Turkey, and Department of Obstetrics and Gynecology (Dr. Peker), Istinye University School of Medicine, Liv Hospital, Istanbul, Turkey. ABSTRACT Study Objective: To demonstrate a step by step surgical hysteroscopy technique in a patient with asymmetric uterine septum and transverse uterine septum that was not previously described in the literature. Design: Resection of an asymmetric uterine septum by laparoscopy and ultrasound-guided hysteroscopy (Canadian Task Force classification III). The video was assumed exempt from official review by our institutional review board. Setting: A septate uterus is defined as the uterus in which the uterine cavity is longitudinally divided by the septum [1]. The most common uterine anomaly, septate uterus has a spectrum of configurations ranging from complete septate to incomplete septate uterus. Asymmetric uterine septum was reported only as case reports in the literature and is described as Robert’s uterus [2]. This unique malformation is described as a septate uterus with a noncommunicating hemicavity, composed of a blind uterine horn usually with unilateral hematometra, and a contralateral unicornuate uterine cavity. The external uterine shape is normal. The asymmetric septum with transverse uterine septum in the present case has not yet been reported in the literature. Patient: A 29-year-old woman presented to our clinic with primary amenorrhea, cyclic pelvic pain, and the desire to have pregnancy. She previously had failed 2 laparoscopy and hysteroscopy procedures for fertility treatments. Hysterosalpingog- raphy previously had been failed. The patient previously underwent magnetic resonance imaging. The magnetic resonance imaging report states there was no connection between the uterus and cervix. On external genital organs assessment, there was no abnormal sign. Ultrasonography revealed 2 uterine cavities and hematometra. Both ovaries were in normal view. Interventions: In view of her examination findings, the patient was scheduled for laparoscopy and hysteroscopy. Laparoscopy revealed extensive adhesions on both the pelvis and upper abdomen. Initially, the uterus and ovaries were not visualized. Ad- hesiolysis was performed, and normal anatomy was restored. After this step, the operation was continued by laparoscopy and ultrasound-guided hysteroscopy. Under ultrasound and laparoscopy guidance, the transverse uterine septum at the level of uterine isthmus was incised and the left endometrial cavity was observed with hysteroscopy. The asymmetric uterine septum was then incised, and the right-sided endometrial cavity was then accessed. Finally, the uterine septum was completely incised and both sides of the endometrial cavities were merged. The patient had an uncomplicated postoperative course and was dis- charged 24 hours after surgery. She returned for follow-up examination in the second month after surgery. She had regular menstrual cycles, and her pain was cured. Conclusion: Hysteroscopy and laparoscopy combined with ultrasound is a useful method for the diagnosis and treatment of asymmetric uterine septum. The skill and experience of the laparoscopic surgeon is another important factor to identify and manage unusual uterine malformations. Journal of Minimally Invasive Gynecology (2018) 25, 28–29 Ó 2017 AAGL. All rights reserved. Keywords: Asymmetric uterine septum; Hysteroscopy; Uterine septum The authors declare that they have no conflict of interest. E-mail: [email protected] Corresponding author: Fatih Sendag, MD, Ege University School of Medi- cine, Department of Obstetrics and Gynecology, Bornova, Izmir 35100, Submitted March 24, 2017. Accepted for publication June 18, 2017. Turkey. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2017 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2017.06.015 Biler et al. Rare Uterine Malformation 29 Supplementary Data Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.jmig.2017.06.015. References 1. Grimbizis GF, Gordts S, Sardo AD, et al. The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Hum Reprod. 2013;28:2032–2044. 2. Robert H. Asymmetrical bifidities with unilateral menstrual retention (apropos of 12 cases). Chirurgie. 1970;96:796–799..