gartner cyst

8/20/2019 Gartner Cyst

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Abstract We present two patients with Gart-

ner’s duct cyst managed with simple marsupial-ization and successful long-term follow up.

Keywords Gartner duct cyst Æ Vaginal mass Æ

Urinary obstruction Æ Mesonephric duct Æ

Marsupialization

Introduction

Gartner’s duct cyst (GDC) is a remnant of the

distal end of the mesonephric duct (Wolffian) infemales. 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 thevaginal 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

ureter has been described on only four occasions,and only once in a neonate [2].

Case-1

A 1-month-old baby girl with antenatal diagnosis

of bilateral hydronephrosis more marked in the

left side was born by induced vaginal delivery at38 weeks due to worsening hydronephrosis.

Postnatal ultrasound scan (USS) revealed gradethree right hydronephrosis and multicystic dys-plastic left kidney. Physical examination was

remarkable for an introital mass more toward the

left wall of the vagina (Fig. 1). The urethralopening was unremarkable.

Cystoscopy showed a normally located rightureteric orifice, no left orifice was seen, and an

elevated left hemitrigone. Marsupialization of thecyst drained a clear fluid, and endoscopic exami-

nation 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 orificeseen. 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. RepeatUSS at 1 year showed a normal right kidney in

addition to the previously seen dysplastic left one.

S. Binsaleh Æ M. Al-Assiri Æ R. Jednak Æ

M. El-SherbinyDivision of Pediatric Urology, Montreal Children’sHospital, McGill University Health Center, Montreal,Canadae-mail: [email protected]

Int Urol Nephrol

DOI 10.1007/s11255-006-9049-x

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O R I G I N A L P A P E R

Gartner duct cyst simplified treatment approach

Saleh Binsaleh

Mana Al-Assiri

Roman Jednak

Mohammed El-Sherbiny

Received: 27 April 2006 / Accepted: 15 May 2006 Springer Science+Business Media B.V. 2006



Case-2

A 10-months old girl presented with a history

only significant for chronic constipation andstraining since birth. The child was referred to

urology for the evaluation of a vaginal swelling

discovered by the mother, seen more prominentduring straining.

Examination was remarkable for a bluish tensecystic mass arising from the vulva, more close to

the right lateral vaginal wall. Urethral meatus wasnormal 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 measuring6.5 · 4.5 cm.

DMSA scan confirmed a normally functioning

solitary left kidney and no function in the pelvic

cystic mass.

Decision was made to examine the mass underanesthesia and to perform cystoscopic examina-

tion. By inspection the vagina and cervix looked

basically normal. The mass was located as de-scribed above. Cystoscopic examination revealed

a normally looking bladder mucosa, normal left

ureteric orifice, and absent right one. Aspirationwas done and the fluid was sent to cytology andbiochemistry that was compatible with urine fluid.

Cyst marsupialization was done through the va-gina. Endoscopic examination inside the cyst re-

vealed a tubular structure ending up in the pelvic

cystic mass that likely represents an obstructedpelvic kidney. Follow-up USS one-month post-

procedure revealed marked decrease in the pelvic

mass size to 2.0 · 1.5 cm, and further follow-upUSS at 3 months revealed complete disappear-

ance of this mass. Patient continued to be seen till6 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, vaginaand the vulva. Patients who present in adult life

typically complain of dyspareunia, disfigurement,

mass filling or fullness in the vagina. If discoveredearly in life, usually presents as an external gen-

italia mass, abdominal pain, vaginal discharge,

recurrent urinary tract infection, incontinence, orenuresis [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 possi-

bility of GDC as opposed to an ureterocele in

patients with ipsilateral renal dysgenesis. The cystis 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 pres-sure 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 isthick. The ureter emptying into the cyst is small

or normal in caliber [1].Fig. 2 After cyst marsupialization to the vagina

Fig. 1 Vaginal mass representing the GDC

Int Urol Nephrol

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The etiology of this condition is believed to bethe result of three developmental anomalies

during embryogenesis: first, cranial displacement

of the ureteric bud; second, incomplete incorpo-ration of the distal Wolffian duct into the uro-

genital sinus; and third, incomplete absorption of

this duct into the Mullerian duct. Persistence,therefore, produces a GDC with an ectopic ureterinserting into the cyst rather than into the bladder

or the vagina [4].

GDC can be confirmed by direct cyst punctureand injection of contrast medium. It may show a

communication with the genital tract. Among alldiagnostic modalities, MRI is the modality of

choice for diagnosing this condition [5].

Asymptomatic masses can be observed andsurgery 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 injuryto the nearby structures such as the urethra, blad-

der, and ureters, with subsequent genitourinary

fistula development. In clitoral and hymenalGartner cysts, injuries to the sensory nerves of

erogenous areas as well as removal of much skinmay result in sexual frigidity or loss of orgasm

during sexual intercourse, which is very frustrating

for both wife and her husband. Other postopera-tive complications include pain, hemorrhage and

dyspareunia [7]. Laser surgery can help in mini-mizing such complications.

Abd-Rabbo et al. [7] described a novel method

for management of such cysts with aspiration and5% tetracycline sclerotherapy with good results

and no side effects.

Cyst marsupialization is a simple, minimallyinvasive procedure, created minimal surgical

scarring, and resulted in the pathological diag-

nosis of a GDC. Long-term follow-up after suchprocedure prove its efficacy, with no demon-strated side effects or recurrence (up to 6 years as

seen in the second case).

These two cases required only simple mar-supialization to manage the cyst with no urinary

incontinence encountered afterwards as bothassociated ipsilateral renal units have no func-

tion, however if the cyst is associated with anectopic ureter from a functioning renal unit then

further surgical intervention (such as ureter re-

implantation or resection of the hypoplastic

kidney) may be necessary to eliminate urinarydribbling.

Conclusions

Persistent GDC is a rare condition. It should be

considered when an intrapelvic or retrovesical

mass with ipsilateral renal dysplasia is found. Cystmarsupialization through the vagina is a simple,

safe, and effective procedure for infants and

children with such diagnosis, and can replace cystexcision.

References

1. Kalva SP, Rammurti S, Subbarao D, Chittibabu N,Murthy VS (2001) Small ureterocele-like Gartner’s ductcyst associated with ipsilateral renal aplasia: a case re-port. Australas Radiol 45(1):62–63

2. Holmes M, Upadhyay V, Pease P (1999) Gartner’sduct cyst with unilateral renal dysplasia presenting as

an introital mass in a newborn. Pediatr Surg Int15:277–279

3. Goldstein AI, Ackerman ES, Woodruff R, Poyas J(1973) Vaginal and cervical communication with meso-nephric duct remnants: relationship to unilateral renalagenesis. Am J Obstet Gynecol 116(1):101–105

4. Currarino G (1982) Single vaginal ectopic ureter andGartner’s duct cyst with ipsilateral renal hypoplasia anddysplasia (or agenesis). J Urol 128(5):988–993

5. Sheih CP, Li Y, Liao YJ, Chiang CD (1996) Smallureterocele-like Gartner’s duct cyst associated withipsilateral renal dysgenesis: Report of 2 cases. J ClinUltrasound 24:533–535

6. Sheih CP, Li YW, Liao YJ, Huang TS, Kao SP, Chen

WJ (1998) Diagnosing the combination of renal dys-genesis, Gartner’s duct cyst and ipsilateral Mu ¨ llerianduct obstruction. J Urol 159:217–221

7. Abd-Rabbo MS, Atta MA (1991) Aspiration and tet-racycline sclerotherapy: a novel method for manage-ment of vaginal and vulval Gartner cysts. Int J GynecolObstet 35:235–237

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