Navigating Complexity: Advanced Visualization for Müllerian Anomalies and its implications for diagnoses and surgical planning.

Abstract

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 eight MRIs and six ultrasounds over seven 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 one 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.