Reviewer’s report
Title: 
Inappropriate surgery in a patient with misdiagnosed Robert’s uterus: A
case report
Version: 
0 
Date: 
15 May 2021
Reviewer: 
Francesca Cisotto
Reviewer's report:
This manuscript of Kisu et colleagues (entitled Disadvantageous surgery in a
patient with misdiagnosed Robert's uterus: a case report) addresses an interesting
topic considering the extremely rarity of the condition and the potential deep
impact on patient's quality of life.
Robert's uterus is a rare Mullerian anomaly (ESHRE-ESGE U2bC3V0),
characterized by asymmetrical septate uterus with a non communicating
hemicavity, a contralateral unicornuate uterine cavity and a normal shaped
external uterine fundus. The blind hemi-cavity with a functional endometrium
causes menstrual retention, leading to unilateral hematometra, hematosalpinx
and eventually endometriosis. The retention of menstrual blood frequently
causes periodical abdominal pain increasing near menstruations. The diagnosis is
difficult and a wrong assessment determines 
inadequate clinical choices. 
The authors present a case report of a 16-year-old woman with severe lower
abdominal pain every month, that was suspected suffer from a uterine
malformation. They misdiagnosed Robert's uterus as a unicornuate uterus with a
non communicating rudimentary horn with hematometra and performed a
laparoscopic hemi-hysterectomy. Although the symptoms were relieved, the
surgical procedure removed a significant portion of uterus making the cavity
smaller and left a weak lateral uterine wall. This treatment could decrease the
probability of conception and increase the risk of uterine rupture in future
pregnancies.
I really appreciated the Author's critical analysis of the followed diagnostic and
therapeutic workup which leads to a misdiagnosis. Key steps were clearly
reported and supported with useful figures both of radiological and
intraoperative findings. MRI figures at 3 years allowed to understand the real
long term outcomes of the performed surgery, frequently missing in other
Robert's uterus case reports.
In my opinion, the most important limitation of this paper is to not completely
analyze the best approach to reduce the risk of misdiagnosed Robert's uterus. In
the discussion the possibility of 3D ultrasound technique is mentioned at line
159 but it should be thoroughly investigated, considering the increased and
actual spreading of this technique. 3D ultrasonography is an effective alternative
to MRI providing images of very similar quality to MRI. Moreover, US is well
tolerated, economically favorable and easily available in routine clinical practice
(I suggest to consider these papers: doi:10.1002/uog.15976; doi:
10.1007/s00404-019-05050-x).
Hysteroscopic metroplasty with ultrasound and laparoscopic guidance is
nowadays considered 
the first choice of treatment. Nonetheless, guidelines are
not available and considering the young age of of the usually treated patients, I
advise to report the possibility of a minimally invasive hysteroscopic
metroplasty guided by transrectal ultrasound, avoiding the need for laparotomy
or lapasoscopy, 
as reported in literature (doi: 10.1002/uog.15976).
The need of a tailored approach should be stressed in the discussion, taking in
account the age of the patient, concurrent adenomyosis or endometriosis and
patient desire to preserve fertility.
Knowledge of this Mullerian anomaly is the key to conduct an adequate
preoperative diagnostic workup, to avoid misdiagnosis and a consequent
inappropriate management.
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