Gartner's duct cysts: a review of surgical management and a new technique using fluorescein dye.

INTRODUCTION AND HYPOTHESIS: Gartner's duct cysts (GDC) are benign lesions that may become symptomatic, leading to surgical intervention. There is no standard surgical technique for management of GDC. This article provides a comprehensive review of surgical the management of GDC. We also present a new technique using fluorescein dye to help delineate GDC walls and facilitate complete cyst excision. METHODS: We conducted a PubMed search for English-language articles without a defined time range. The search combined subject headings, title, abstract, and text words relating to Gartner duct cysts. Articles describing surgical management of GDC were included. Exclusion criteria included inadequate diagnosis of GDC, infected cysts, nonsurgical management, or article unavailable for interlibrary loan. A novel approach using intra-cyst fluorescein dye injection is described. RESULTS: Two hundred sixty-seven articles were identified via PubMed, and 34 articles were included in the review based on eligibility criteria. Concomitant genitourinary malformations occurred in 19 of the 92 surgically managed patients. Surgical techniques included cyst excision (50 patients), tetracycline injection following aspiration (15), marsupialization (14), unroofing/partial excision (9), and puncture/evacuation (4). Recurrences occurred in 4, 1, 0, 0, and 1 patient, respectively. One patient underwent uncomplicated fluorescein dye-assisted cyst excision with no recurrence 30 months post-procedure. CONCLUSIONS: The low incidence of GDCs necessitating surgical intervention has resulted in a lack of standard surgical technique, especially in patients with concurrent genitourinary malformations. Utilizing fluorescein dye provides a surgical method that can help confirm the absence of urologic involvement as well as facilitate precise excision of GDC.

Clinical Manifestations and Outcomes in Surgically Managed Gartner Duct Cysts.

STUDY OBJECTIVE: Gartner duct cysts (GDCs) are rare embryological remnants of the mesonephric duct with the majority of cases discovered incidentally in asymptomatic patients. The largest prior published series evaluating the surgical management of GDCs included 4 patients. The present study aimed to determine the manifestations and outcomes of surgically managed patients with GDCs with important implications for surveillance, monitoring, and management. DESIGN: A retrospective chart review (Canadian Task Force classification III). SETTING: A tertiary care center. PATIENTS: All women diagnosed with GDCs from January 1994 to April 2014 at our institution were identified. Patients were included if they underwent surgical management and had GDCs confirmed by pathology. One hundred twenty-four charts were manually reviewed, and 29 patients were included in the analysis. INTERVENTIONS: All patients underwent surgical management, which included vaginal excision or marsupialization. MEASUREMENTS AND MAIN RESULTS: A total of 29 patients met the inclusion criteria for this study. The median age of the patients included in the analysis was 36 years old. Eleven patients were asymptomatic at the time of diagnosis (37.9%). The reason for surgical intervention was not available in 9 of these patients. Surgical intervention was performed in 2 of the 11 asymptomatic patients because of an increasing size of the lesion during observation. Presenting symptoms included dyspareunia or pain with tampon placement (37.9%), pelvic pain or pressure (24.1%), pelvic mass or bulge (17.2%), and urinary incontinence (6.9%). Preoperative imaging studies were obtained in 62% of patients; ultrasound was used in 44.4%, computed tomographic scanning in 22.2%, magnetic resonance imaging in 16.7%, and multiple modalities in 16.7%. Approximately 10% were found to have other genitourinary anomalies, including a bladder cyst, urethral diverticulum, and a solitary right kidney with uterine didelphis and septate vagina. The average cyst size was 3.5 cm (±1.8 cm). Surgical excision of GDCs was performed in all except for 3 cases of marsupialization. No intraoperative complications occurred. The median follow-up was 82 months (range, 0-246 months). One patient had possible recurrence with dyspareunia and protruding tissue diagnosed 14 months postoperatively. There were no other postoperative complications in the follow-up period. CONCLUSION: GDCs are rare pelvic masses that are often asymptomatic but may present with dyspareunia, pelvic pain or pressure, pelvic mass or bulge, or urinary symptoms. Excision or marsupialization is successful in the majority of cases without significant morbidity.

Bilateral isolated Epididymal Agenesis in a 32 year old man.

Epididymal agenesis is defined as the absence of the epididymis totally or segmentally, unilateral or bilateral, which is secondary to the Wolffian duct malformation (1). Rete testis, epididymis, vas deferens and seminal vesicle are believed to develop from Wolffian ducts.

Vaginal Gartner cysts: clinical report of four cases and a bibliographic review.

OBJECTIVES: To present a series of four cases of Gartner cysts and their clinical presentation. A bibliographic review was performed. METHODS: The series consisted of 4 women, mean age 39, who complained of a bulge at the anterior vaginal wall, associated with a variety of urinary symptoms. RESULTS: Surgical removal was performed in all cases. The pathological studies confirmed the diagnosis of Gartner cyst. There were no recurrences in the long-term follow-up. CONCLUSION: Vaginal wall cysts are rarely found in common urological practice. Gartner cysts arise as a consequence of the Gartner duct (mesonephric remainder) obstruction and they are located in the anterior or lateral wall of the vagina. They may be associated with renal and ureteral anomalies. Differential diagnosis with other vaginal cysts can only be made by histological studies. The correct treatment is the entire removal through a vaginal approach.

Incidental mesonephric remnant hyperplasia of the jejunal mesentery: A diagnostic challenge.

Mesonephric remnants are embryonic vestiges of the mesonephric (Wolffian) ducts which regress during normal development. These remnants have been uncommonly reported in the female and male reproductive tract as a spectrum of morphologic lesions that can be misdiagnosed as carcinoma. One case of mesonephric remnant hyperplasia of the jejunal mesentery incidentally found in a 47-year-old man is herein reported. This is the first description of mesonephric hyperplasia arisen in the mesentery. The presence of ducts, tubules, and cysts lined by bland, epithelial, cuboidal cells with scant cytoplasm, and diffuse pseudoinfiltrative growth pattern can raise the possibility of neoplasia. Immunohistochemically, mesonephric epithelia have a characteristic staining. CD10 highlights the apical-luminal aspect of the cells. Besides, intense reactivity is showed for high-molecular-weight cytokeratin (CK), CK7, bcl2, and vimentin. The main differential diagnosis includes mesothelial hyperplasia, epithelial mesothelioma, well-differentiated neuroendocrine tumor, and infiltration due to acinar adenocarcinoma of the prostate. However, a detailed microscopic study with the aid of immunohistochemistry helps separate mesonephric remnants from malignant processes. The mesonephric hyperplasia of the mesentery we have reported adds to the spectrum of mesonephric remnants a new location. Familiarity with this lesion is indispensable to avoid overdiagnosis.

Mayer-Rokitansky-Küster-Hauser syndrome with rare findings of inferior crossed-fused renal ectopia and Gartner's duct cyst: a video case report.

OBJECTIVE: To describe the treatments of a patient using the laparoscopic Davydov's method for Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and ureteral reimplantation for hydronephrosis and hydroureter. DESIGN: Surgical video article. A consent form from the patient was obtained as appropriate; the nature of the study did not necessitate ethics committee approval. There were no conflicts of interest. SETTING: University hospital. PATIENT(S): A 28-year-old woman who presented at our gynecology department with the symptoms of primary amenorrhea and difficult intercourse. She had repaired congenital rectovestibular fistula and imperforate anus at the age of 8. At physical examination, she had a phenotypically normal vulva with a vaginal small pouch (0.5 cm). Magnetic resonance imaging of the pelvis revealed normal ovaries, a primordial uterus, absence of vaginal canal, and a 4.0 × 4.2 × 4.0 cm cystic structure posterior to the bladder. Magnetic resonance urography showed right to left renal crossed-ectopia with inferior fusion, and hydronephrosis and hydroureter from the superior kidney with Grade Ⅳ vesicoureteral reflux. Karyotype was 46, XX. INTERVENTION(S): Saline solution 300 mL was injected into the rectovesical space with an infusion of diluted adrenaline (1:200,000). The goal of this injection was to aid in the identification of tissue planes and reduce blood loss. The space between urethra/bladder and rectum progressively was dissected. Blunt dissection was performed initially with digital separation of tissues. Then, an 8-cm-long neovaginal vault of about 3 cm in diameter was created. The mobilized peritoneum was pulled downward with eight Vicryl sutures and connected to the vaginal epithelium. By cystoscope, we found the left orifice but could not find the right orifice of the hydroureter. Then we ligated the hydroureter by 2-0 absorbable suture near the cyst and cut off the hydroureter, and then incised of all the layers at the top of the bladder to make a bladder flap. We placed the 5 Fr double J stent in the hydroureter and the bladder and anastomozed with the ureteral stump (3-0 Vicryl). Then we removed the cyst laparoscopically. We performed a purse-string stitch to create the apex of the neovagina by taking posterior serosa of the bladder, the pelvic peritoneum between the ovary and rectum, primordial uterus, and anterior rectal serosa. MAIN OUTCOME MEASURE(S): Measurement of the final canal length, sexual function (Female Sexual Function Index), and degree of hydronephrosis. RESULT(S): Three days later, we started to change the vaginal mold and the patient was advised to wear it day and night for the first postoperative month. The vaginal mold had to be worn each night until normal sexual intercourse was possible. Findings confirmed the cyst was Gartner's duct cyst. One year after the surgery, the final canal length was 9 cm and Female Sexual Function Index score was 28. The ultrasound showed that the degree of hydronephrosis of upper moiety was mild. CONCLUSION(S): The distal Wolffian ducts in the female are absorbed but may persist as vestigial remnants (Gartner's duct cysts). A few cases of the combined urogenital-Wolffian anomalies are reported; most of them are associated with the anomalies of müllerian duct fusion, such as Herlyn-Werner-Wunderlich syndrome (uterus didelphys, obstructed hemivagina, and mesonephric duct anomalies). The embryogenesis of the combined anomalies is not completely understood. With comprehensive preoperative assessments, laparoscopic surgery could be a safe and effective treatment to these cases.

Dedifferentiated Mesonephric-like Adenocarcinoma of the Uterine Corpus.

BACKGROUND/AIM: We present a case of uterine dedifferentiated mesonephric-like adenocarcinoma (MLA). CASE REPORT: A 54-year-old woman underwent total hysterectomy for a uterine mass under the impression of a uterine sarcoma. Histologically, MLA exhibited various growth patterns including tubular and glandular architecture. Undifferentiated carcinoma (UC) displayed discohesive tumor cells without any obvious architecture. Immunohistochemically, UC was positive for epithelial markers in very few scattered tumor cells. MLA exhibited the wild-type p53 expression pattern, whereas UC showed a uniform and strong p53 immunoreactivity. Targeted sequencing analysis revealed an identical Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation in both components. A pathogenic missense tumor protein 53 (TP53) mutation was detected in UC, but not in MLA. CONCLUSION: The mutant p53 expression pattern exclusively detected in UC was concordant with the presence of missense TP53 mutation. Our observations suggested that TP53 mutation is associated with the possible transformation from MLA to UC.

Gartner's Duct Cyst of the Vagina: A Case Report.

Paramesonephric duct or Mullerian ducts forms female genital organs whereas mesonephric duct forms male genital organs. The remnant of the mesonephric duct or Wolffian duct in females sometimes forms a mesonephric cyst or Gartner's duct cyst. They are usually asymptomatic and <2 cm but sometimes can be bigger. It is diagnosed with pelvic examination. It is treated with surgical excision of the cyst. This is a unique case in urogynecology as it confuses with pelvic organ prolapse and the mode of treatment is completely different. We report a case of 32-years old lady who presented in urogynecology outpatient department with complain of pelvic organ prolapse. After examination she was diagnosed as vaginal cyst and excision was done and confirmed as Gartners cyst in histopathological examination.

Tubulocystic anomalies of the mesonephric duct associated with ipsilateral renal dysgenesis.

INTRODUCTION: Renal agenesis and multicystic dysplastic kidney (MCDK) are usually associated with either an absent or atretic ureter. Occasionally, these renal anomalies may be associated with a dilated tortuous ureter, ureterocele or other cystic malformation of mesonephric duct (MND) remnants. OBJECTIVES: The objective of this study was to identify and classify anatomical variants of tubulocystic remnants of the MND, with a secondary focus on natural history and management outcomes. PATIENTS AND METHODS: A retrospective cohort study of patients seen in the study institution between 2007 and 2014 with a tubulocystic abnormality of MND structures associated with either MCDK or renal agenesis was conducted. Medical imaging and progress notes were reviewed for all patients. Data collected included anatomical information, surgical intervention, histology and outcomes of both conservatively managed and surgically resected MND remnant structures. RESULTS: Nineteen patients were identified, 5 girls and 14 boys. Median age at presentation was 4.6 years. Anomalies of the MND occurred on the left in 9 patients and on the right in 10 patients. Mean follow-up was 3.4 years. Patients fell into 3 distinct anatomical groups: Type I, including orthotopic remnants corresponding to ureteric bud structures (ureter and trigone); Type II, including ectopic MND remnants of ureteric bud structures, and Type III, including complex remnants corresponding to MND structures other than those from ureteric bud (vas, epididymis and seminal vesicles). Anomalies of structures arising from urogenital sinus and paramesonephric ducts were also identified. Most patients were asymptomatic and successfully managed conservatively. Transvesical puncture of trigonal cysts provided effective decompression in 5 patients. Partial or complete MCDK regression was seen in 7 patients, whereas MND cystic anomalies did not regress spontaneously. DISCUSSION: When MND tubulocystic structures persist along with renal agenesis or MCDK, most arise from ureteric bud structures in an orthotopic position as a ureterocele with or without a blind-ending ureter-like structure. Less commonly, ureteric bud structures insert ectopically into the urogenital tract, or tubulocystic structures arising from the remainder of the MND occur. Embryogenesis of other urogenital structures may also be abnormal, and conditions such as Zinner syndrome and obstructed hemivagina and ipsilateral renal agenesis syndrome should be considered. CONCLUSIONS: Complications are uncommon, and surgical intervention should be limited to symptomatic patients. Remnants of metanephric blastema may involute, but MND remnants persist.

A Gartner duct cyst of the vagina causing dysuria and dyschezia in a Yorkshire terrier.

A 5 year-old, intact female Yorkshire terrier was referred for dysuria and dyschezia. The radiographic and ultrasound examination showed a round shaped mass caudal to the urinary bladder that contained anechoic fluid within the thin walls. During surgery, the cyst was noted to be attached to the outer wall of the vagina, not connected to the vaginal lumen. Cystic fluid was removed and the cystic wall was resected. Then the remaining cystic wall was omentalized to prevent a recurrence. Histological examination confirmed that the cyst was of Wolffian duct origin. In this case, a large Gartner duct cyst causing urological problems was diagnosed and removed by surgical resection.

Zinner Syndrome: A Diagnostic Challenge. The Aid of Morphology, Embryology, and Immunohistochemistry.

We investigate a patient with right kidney agenesis. Imaging showed the presence of a cystic mass dislocating the bladder. The specimen showed three formations: a kidney remnant, a ureter with blind-ending branch, and a cyst, from which departed another tubular structure, considered the deferential duct. The specimen was sampled. The supposed kidney was formed by cystic structures. Examination of the tubular structures disclosed smooth muscle fibers with no lumen, whereas the cyst was surrounded by fibrous and hemorrhagic walls. Collaboration among specialists allowed the diagnosis of Zinner syndrome, a congenital malformation due to an abnormal development of the Wolffian duct.

Quiste de Gartner de localización uterina / Gartner's cyst of uterine location

RESUMEN Los quistes de los conductos de Gartner, generalmente pequeños, benignos y asintomáticos, son vestigios del canal mesonéfrico de Wolff. Representan el 11 % de los quistes vaginales, esta es su localización más frecuente según la literatura consultada. Se presentó un caso operado en el Hospital Militar de Matanzas "Dr. Mario Muñoz Monroy", de localización en la cara posterior del istmo uterino (AU).

ABSTRAC Gartner's duct cyst, mostly little, benign and asymptomatic, are vestiges of the Wolffian mesonephric duct representing 11 % of the vaginal cysts; this location is the most frequently reported and published one up to date. The authors presented the case of a patient who underwent a surgery in the Military Hospital "Dr. Mario Muñoz Monroy¨ with a cyst in the posterior side of the uterine isthmus (AU).

Recurrent giant Gartner's duct cysts. A report of two cases.

BACKGROUND: Gartner's duct cysts are cystically dilated wolffian duct remnants found in the upper anterolateral part of the vagina. Many such giant cysts are diagnosed during childhood and result from ectopic communication with the ureter or cervix. There is a paucity of literature on recurrent and giant cysts presenting among older women. CASES: A 43-year-old woman presented in 1981 with a 7 x 14-cm, left, paravaginal, cystic mass. This was initially drained vaginally, then marsupialized vaginally. Following marsupialization, the patient began to note large gushes of fluid from the vagina. Ultrasound demonstrated a 3-cm cyst thought to arise within the broad ligament. The patient required total abdominal hysterectomy/bilateral salpingo-oophorectomy for endometrial hyperplasia. Exploration revealed neither a broad ligament nor vaginal mass. Postoperatively, vaginal drainage continued. Computed tomography demonstrated a multiloculated, cystic mass left of the vaginal cuff. Exploratory laparotomy revealed the mass to be within the paravaginal space. The cyst was marsupialized into the peritoneal cavity. A 32-year-old woman was diagnosed in 1992 with an 8 x 10-cm right pelvic mass found on examination and confirmed by computed tomography. At exploratory laparotomy the mass was found to be within the paravaginal space and was resected vaginally. In 1999 the patient returned, complaining of rectal pain. Examination and ultrasound revealed a right, multiloculated pelvic mass displacing the rectum, uterus and vagina. Magnetic resonance imaging demonstrated that the mass was entirely inferior to the levator plate. The cyst was resected vaginally. CONCLUSION: Giant Gartner's cysts tend to be misdiagnosed as pelvic masses. Magnetic resonance imaging is the best imaging modality for localizing these cysts. Recurrences of giant cysts tend to be multiloculated. Management strategies for multiloculated recurrences include periodic surveillance, schlerotherapy and marsupialization into the peritoneal cavity.

Hydatid of morgagni with torsion diagnosed during cesarean delivery. A case report.

BACKGROUND: Hydatids of Morgagni are benign, pedunculated, cystic structures arising from müllerian vestiges below the fallopian tube near the fimbria. They usually are of no clinical significance unless the pedicle becomes twisted and infarction occurs. CASE: A 39-year-old primigravida at 41 weeks and 5 days' gestation underwent primary cesarean delivery for macrosomia and failure to descend during labor. A 4 x 3-cm hydatid of Morgagni with torsion of the pedicle was found on the left fallopian tube. Ligation of the pedicle and excision of the infarcted cyst were performed. Histology of the specimen demonstrated cuboidal epithelium with extensive hemorrhage and necrosis, consistent with an infarcted hydatid of Morgagni. All pain and symptoms experienced by the patient during the previous day were associated with the onset of labor. No specific left lower quadrant pain was reported. CONCLUSION: Hydatids of Morgagni are common findings at pelvic surgery and usually of no clinical significance. Torsion of a hydatid of Morgagni is rarely reported and most likely is a rare occurrence. In this patient, torsion of the hydatid of Morgagni was possibly pregnancy related, and symptoms associated with torsion were probably masked by labor pain.

[An ectopic ureter with communication to the duct of Gartner and opening into the cervix--a rare cause of uncontrolled urine loss]. / Ektoper Harnleiter mit Verbindung zum Gartner-Gang und Mündung in die Zervix--eine seltene Ursache unwillkürlichen Urinverlusts.

This is a report of a 22-year-old woman who suffered from a loss of urine via the vagina of unknown origin since childhood. The diagnosis of a left ureteral and renal duplication with an opening of an ectopic ureter into the cervix was established. Due to the result of the retrograde pyelogram we came to the conclusion that the opening into the cervix must have been via a segment of a Gartner duct. The ectopic system and the Gartner duct were completely removed by a combined abdomino-vaginal operation. Genesis, diagnostics, differential diagnostics and therapy of ectopic ureters are described.

[Bilateral persistence of the common mesonephric duct in children. Apropos of a case. Review of the literature]. / Persistance bilatérale du canal mésonéphrotique commun chez l'enfant. A propos d'un cas. Revue de la littérature.

We report a case of bilateral persistence of the common mesonephric duct in a child. This anomaly is an error of implantation of the vas deferens in the distal part of the Wolffian duct. This abnormality is extremely rare (6 cases have been reported in the world literature). The diagnosis is usually incidental during laparotomy or on retrograde cystography (vesico-ureteric and vesico-deferential reflux). It is simple to treat: bilateral deferential ligation in view of the context of multiple malformations, in order to prevent ascending genital infections (prostatitis, epididymitis, testicular abscess). Only one case has been reported in adults, presenting in the form of a septic complication. This diagnosis must be considered in a context of atypical urogenital infection in a subject with other congenital abnormalities.

Giant Gartner duct cyst and elevated CA-125.

BACKGROUND: Gartner duct cysts represent vestigial remnants of the caudal end of the mesonephric (Wolffian) ducts. They are often associated with ureteral and renal abnormalities. In most cases they are solitary, less than 2 cm in diameter. Giant Gartner duct cysts are extremely rare. CASE: We present a girl with a giant Gartner duct cyst, without notable associated abnormalities or pathology, successfully treated by surgical excision. Preoperative aspiration revealed elevated level of CA-125 in the cyst fluid, with normal serum level of the same marker. CONCLUSION: Analyzing the aspirated fluid for CA-125 may be a useful tool for evaluation of cystic lesions in this region.

Mesonephric adenocarcinoma of the uterine corpus.

Mesonephric carcinomas are rare in the female genital tract and usually are found in sites where embryonic remnants of wolffian ducts are usually detected, such as the uterine cervix, broad ligament, mesosalpinx and exceptionally rarely in the uterine corpus. To date, only four cases of mesonephric carcinomas arising in the uterine corpus have been described in literature. Here we report two cases of mesonephric carcinomas arising in a deep intramural location of the uterine corpus in a 55-year-old woman and a 62-year-old woman in Chinese populations. It is believed to be the first report in China. Both cases presented with a little postmenopausal bleeding. Before hospitalized, uterine curettages were programmed for both cases. The pathology reports were mesonephric adenocarcinoma. A total hysterectomy and bilateral salpingo-oophorectomy were performed. On gross examination, the tumors of both cases were confined to the myometrium. Microscopic examination found both tumors of these two cases were adenocarcinomas mixed with spindle cell component. The most primary histologic patterns of the mesonephric adenocarcinomas were tubular glands that varied in size and were lined by one to several layers of columnar cells. Immunohistochemically, the tumor cells expressed positive with CD10, calretinin, vimentin, cytokeratin (AE1/AE3) and epithelial membrane antigen (EMA); but expressions of ER and PR were completely negative. The peculiar location of mesonephric carcinoma of the uterine corpus may be misinterpreted as other histological type neoplasms. Awareness of this rare phenomenon and immunostaining for markers of mesonephric carcinoma can prevent from making a false diagnosis.