Int Urol Nephrol DOI 10.1007/s11255-006-9049-x ORIGINAL PAPER Gartner duct cyst simplified treatment approach Saleh Binsaleh Æ Mana Al-Assiri Æ Roman Jednak Æ Mohammed El-Sherbiny Received: 27 April 2006 / Accepted: 15 May 2006 Springer Science+Business Media B.V. 2006 Abstract We present two patients with Gartner’s duct cyst managed with simple marsupialization and successful long-term follow up. ureter has been described on only four occasions, and only once in a neonate [2]. Keywords Gartner duct cyst Æ Vaginal mass Æ Urinary obstruction Æ Mesonephric duct Æ Marsupialization Case-1 Introduction Gartner’s duct cyst (GDC) is a remnant of the distal end of the mesonephric duct (Wolffian) in females. This anomaly is often associated with other developmental anomalies related to the mesonephric duct such as an ectopic ureter, communication with the vagina, and ipsilateral renal agenesis. Usually the cysts are solitary, small, but can be large enough to bulge from the vaginal outlet. This condition is extremely rare in infants, with fewer than 40 cases reported in literature [1]. Presentation as a vaginal cyst with an ectopic S. Binsaleh Æ M. Al-Assiri Æ R. Jednak Æ M. El-Sherbiny Division of Pediatric Urology, Montreal Children’s Hospital, McGill University Health Center, Montreal, Canada e-mail: [email protected] A 1-month-old baby girl with antenatal diagnosis of bilateral hydronephrosis more marked in the left side was born by induced vaginal delivery at 38 weeks due to worsening hydronephrosis. Postnatal ultrasound scan (USS) revealed grade three right hydronephrosis and multicystic dysplastic left kidney. Physical examination was remarkable for an introital mass more toward the left wall of the vagina (Fig. 1). The urethral opening was unremarkable. Cystoscopy showed a normally located right ureteric orifice, no left orifice was seen, and an elevated left hemitrigone. Marsupialization of the cyst drained a clear fluid, and endoscopic examination of the resultant duct revealed a smooth cavity with a blind end (Fig. 2). The elevated left hemitrigone disappeared after cyst drainage but still no left was orifice seen. Final pathology of the removed cyst wall proves a benign cyst lined by a single row of cuboidal cell, consistent with a GDC. Patient did well post-operatively and follow-up till one year of age was unremarkable. Repeat USS at 1 year showed a normal right kidney in addition to the previously seen dysplastic left one. 123 Int Urol Nephrol Fig. 1 Vaginal mass representing the GDC Case-2 A 10-months old girl presented with a history only significant for chronic constipation and straining since birth. The child was referred to urology for the evaluation of a vaginal swelling discovered by the mother, seen more prominent during straining. Examination was remarkable for a bluish tense cystic mass arising from the vulva, more close to the right lateral vaginal wall. Urethral meatus was normal in size and location. USS revealed a normal left kidney, but the right one was absent. There was a pelvic cystic mass posterior to the urinary bladder measuring 6.5 · 4.5 cm. DMSA scan confirmed a normally functioning solitary left kidney and no function in the pelvic cystic mass. Fig. 2 After cyst marsupialization to the vagina 123 Decision was made to examine the mass under anesthesia and to perform cystoscopic examination. By inspection the vagina and cervix looked basically normal. The mass was located as described above. Cystoscopic examination revealed a normally looking bladder mucosa, normal left ureteric orifice, and absent right one. Aspiration was done and the fluid was sent to cytology and biochemistry that was compatible with urine fluid. Cyst marsupialization was done through the vagina. Endoscopic examination inside the cyst revealed a tubular structure ending up in the pelvic cystic mass that likely represents an obstructed pelvic kidney. Follow-up USS one-month postprocedure revealed marked decrease in the pelvic mass size to 2.0 · 1.5 cm, and further follow-up USS at 3 months revealed complete disappearance of this mass. Patient continued to be seen till 6 years of age and reported no complications, regular bowel habits, and complete dryness day and night throughout this interval. Discussion GDC can be found in the broad ligament, vagina and the vulva. Patients who present in adult life typically complain of dyspareunia, disfigurement, mass filling or fullness in the vagina. If discovered early in life, usually presents as an external genitalia mass, abdominal pain, vaginal discharge, recurrent urinary tract infection, incontinence, or enuresis [2]. The differential diagnosis of an introital mass in a newborn is GDC, ureterocele, ectopic ureter, cystocele, rhabdomyosarcoma, paravaginal glands, and urethral diverticulum [3]. There are a few points that suggest the possibility of GDC as opposed to an ureterocele in patients with ipsilateral renal dysgenesis. The cyst is retrovesical and bulges into the bladder wall. The cyst does not communicate with the bladder, bladder neck or urethra and does not obviously change in shape and size when intravesical pressure increases with bladder filling and voiding. The cyst is located on the vaginal wall and may be connected to the vaginal cavity. The cyst wall is thick. The ureter emptying into the cyst is small or normal in caliber [1]. Int Urol Nephrol The etiology of this condition is believed to be the result of three developmental anomalies during embryogenesis: first, cranial displacement of the ureteric bud; second, incomplete incorporation of the distal Wolffian duct into the urogenital sinus; and third, incomplete absorption of this duct into the Mullerian duct. Persistence, therefore, produces a GDC with an ectopic ureter inserting into the cyst rather than into the bladder or the vagina [4]. GDC can be confirmed by direct cyst puncture and injection of contrast medium. It may show a communication with the genital tract. Among all diagnostic modalities, MRI is the modality of choice for diagnosing this condition [5]. Asymptomatic masses can be observed and surgery usually indicated for symptomatic ones [6]. Surgical excision is frequently associated with bleeding due to the natural vascularity of vagina and vulva. This also might be associated with injury to the nearby structures such as the urethra, bladder, and ureters, with subsequent genitourinary fistula development. In clitoral and hymenal Gartner cysts, injuries to the sensory nerves of erogenous areas as well as removal of much skin may result in sexual frigidity or loss of orgasm during sexual intercourse, which is very frustrating for both wife and her husband. Other postoperative complications include pain, hemorrhage and dyspareunia [7]. Laser surgery can help in minimizing such complications. Abd-Rabbo et al. [7] described a novel method for management of such cysts with aspiration and 5% tetracycline sclerotherapy with good results and no side effects. Cyst marsupialization is a simple, minimally invasive procedure, created minimal surgical scarring, and resulted in the pathological diagnosis of a GDC. Long-term follow-up after such procedure prove its efficacy, with no demonstrated side effects or recurrence (up to 6 years as seen in the second case). These two cases required only simple marsupialization to manage the cyst with no urinary incontinence encountered afterwards as both associated ipsilateral renal units have no function, however if the cyst is associated with an ectopic ureter from a functioning renal unit then further surgical intervention (such as ureter reimplantation or resection of the hypoplastic kidney) may be necessary to eliminate urinary dribbling. Conclusions Persistent GDC is a rare condition. It should be considered when an intrapelvic or retrovesical mass with ipsilateral renal dysplasia is found. Cyst marsupialization through the vagina is a simple, safe, and effective procedure for infants and children with such diagnosis, and can replace cyst excision. References 1. 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