The diagnostic value of high-resolution 3D T2-weighted MRI in preoperative evaluation and classification of Herlyn-Werner-Wunderlich syndrome: a prospective study

Abstract Objective Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare female reproductive tract malformation. Accurate preoperative diagnosis and classification are vital for surgical planning. This study aims to evaluate the diagnostic value of high-resolution three-dimensional (3D) T2-weighted MRI in the preoperative assessment and classification of HWWS. Materials and methods The study prospectively enrolled 84 patients clinically diagnosed with HWWS between May 2020 and January 2025. Seventy patients underwent pelvic MRI examinations, including high-resolution 3D T2 sequences (1 mm slice thickness) and conventional T2 TSE sequences, supplemented by large-field-of-view (FOV) T2 coronal imaging for urinary system evaluation and full-spine X-ray examinations for skeletal assessment. Two experienced radiologists independently evaluated the imaging features in a blinded manner, focusing on uterine morphology, obstruction sites, presence of communications, and related anomalies and complications. Consistency analysis was performed between imaging findings and surgical results in 52 surgical patients. Results Uterine morphology included: didelphys (54/70, 77.1%), complete septate (14/70, 20%), and bicornuate uterus (2/70, 2.9%). Among 52 surgical patients, 31 (59.6%) had vaginal-level obstruction with 18 (34.6%) Type I, 11 (21.2%) Type II, and 2 (3.8%) Type III, and 21 (40.4%) had cervical-level obstruction (Type IV and mixed). 3D T2 sequences identified 7 (63.6%) vaginal septum fistulas, outperforming TSE sequences, which detected none (0%) ( p = 0.005). Associated findings were ipsilateral renal agenesis (98.6%), ovarian endometriosis (22.9%), hematosalpinx (22.9%), and spinal abnormalities (scoliosis (25.7%), mild scoliosis (41.4%). Conclusion High-resolution 3D T2 MRI is superior to conventional T2 TSE sequences in the preoperative evaluation of HWWS, especially for identifying communications and precisely locating obstruction sites. Key Points Question Accurate preoperative structural assessment and classification of HWWS are clinically essential, yet conventional MRI has limitations in identifying fine anatomical structures and small communications. Findings High-resolution 3D T2 MRI outperforms conventional T2 TSE in identifying vaginal and cervical communications and precisely localizing obstruction sites in preoperative evaluation of HWWS. Critical relevance statement This study supports routine inclusion of 3D sequences in HWWS imaging protocols. Combined with renal and spinal assessment, it provides a comprehensive preoperative evaluation that enhances surgical planning precision and optimizes patient management strategies.