Int Urol Nephrol

DOI 10.1007/s11255-006-9049-x

ORIGINAL PAPER

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

Abstract We present two patients with Gartners 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 Vaginal mass

Urinary obstruction Mesonephric duct
Marsupialization

Case-1

Introduction
Gartners 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 M. Al-Assiri R. Jednak

M. El-Sherbiny
Division of Pediatric Urology, Montreal Childrens
Hospital, McGill University Health Center, Montreal,
Canada
e-mail: surgon@hotmail.com

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.

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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

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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. Kalva SP, Rammurti S, Subbarao D, Chittibabu N,
Murthy VS (2001) Small ureterocele-like Gartners duct
cyst associated with ipsilateral renal aplasia: a case report. Australas Radiol 45(1):6263
2. Holmes M, Upadhyay V, Pease P (1999) Gartners
duct cyst with unilateral renal dysplasia presenting as
an introital mass in a newborn. Pediatr Surg Int
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3. Goldstein AI, Ackerman ES, Woodruff R, Poyas J
(1973) Vaginal and cervical communication with mesonephric duct remnants: relationship to unilateral renal
agenesis. Am J Obstet Gynecol 116(1):101105
4. Currarino G (1982) Single vaginal ectopic ureter and
Gartners duct cyst with ipsilateral renal hypoplasia and
dysplasia (or agenesis). J Urol 128(5):988993
5. Sheih CP, Li Y, Liao YJ, Chiang CD (1996) Small
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Ultrasound 24:533535
6. Sheih CP, Li YW, Liao YJ, Huang TS, Kao SP, Chen
WJ (1998) Diagnosing the combination of renal dysgenesis, Gartners duct cyst and ipsilateral Mullerian
duct obstruction. J Urol 159:217221
7. Abd-Rabbo MS, Atta MA (1991) Aspiration and tetracycline sclerotherapy: a novel method for management of vaginal and vulval Gartner cysts. Int J Gynecol
Obstet 35:235237

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