International Urogynecology Journal

https://doi.org/10.1007/s00192-019-04091-9

REVIEW ARTICLE

Gartner’s duct cysts: a review of surgical management and a new

technique using fluorescein dye
Sida Niu 1 & Ryan D. Didde 2 & Jennifer K. Schuchmann 3 & Dani Zoorob 4

Received: 2 July 2019 / Accepted: 15 August 2019

# The International Urogynecological Association 2019

Abstract
Introduction and hypothesis Gartner’s duct cysts (GDC) are benign lesions that may become symptomatic, leading to surgical
intervention. There is no standard surgical technique for management of GDC. This article provides a comprehensive review of
surgical the management of GDC. We also present a new technique using fluorescein dye to help delineate GDC walls and
facilitate complete cyst excision.
Methods We conducted a PubMed search for English-language articles without a defined time range. The search combined
subject headings, title, abstract, and text words relating to Gartner duct cysts. Articles describing surgical management of GDC
were included. Exclusion criteria included inadequate diagnosis of GDC, infected cysts, nonsurgical management, or article
unavailable for interlibrary loan. A novel approach using intra-cyst fluorescein dye injection is described.
Results Two hundred sixty-seven articles were identified via PubMed, and 34 articles were included in the review based on
eligibility criteria. Concomitant genitourinary malformations occurred in 19 of the 92 surgically managed patients. Surgical
techniques included cyst excision (50 patients), tetracycline injection following aspiration (15), marsupialization (14), unroofing/
partial excision (9), and puncture/evacuation (4). Recurrences occurred in 4, 1, 0, 0, and 1 patient, respectively. One patient
underwent uncomplicated fluorescein dye-assisted cyst excision with no recurrence 30 months post-procedure.
Conclusions The low incidence of GDCs necessitating surgical intervention has resulted in a lack of standard surgical technique,
especially in patients with concurrent genitourinary malformations. Utilizing fluorescein dye provides a surgical method that can
help confirm the absence of urologic involvement as well as facilitate precise excision of GDC.

Keywords Gartner . Surgical management . Excision . Fluorescein . Review article

Introduction 1 in 200 women; however, this may be an underestimation, as

Benign cystic lesions of the urogenital tract are commonly
encountered in gynecologic and urologic practices. It has been
estimated that the prevalence of vaginal cysts is approximately
* Ryan D. Didde
rdidde@kumc.edu
1
Department of Urology, University of Kansas Medical Center,
Kansas City, KS, USA
2
University of Kansas School of Medicine, University of Kansas
Medical Center, 3901 Rainbow Blvd. MS 3016, Kansas
City, KS 66160, USA
3
Department of Obstetrics and Gynecology, University of Kansas
Medical Center, Kansas City, KS, USA
4
Department of Obstetrics and Gynecology, University of Toledo
College of Medicine and Life Sciences, Toledo, OH, USA
most cases of vaginal cysts are not reported [1]. In Pradhan
and Tobon’s pathologic review of 43 vaginal cysts over a 10-
year span, the incidence of cyst types was shown to be
Müllerian cysts (44%), epidermal inclusion cysts (23%),
Gartner’s duct cysts (11%), Bartholin’s gland cysts (7%),
and endometriotic type (7%) [2].
Vaginal wall cysts can present in a multitude of ways but
are typically discovered as incidental findings on physical
examination. In many cases, the diagnosis of vaginal cysts is
made using the patient’s history and physical examination.
Gartner’s duct cysts (GDCs) may arise from remnants of the
mesonephric ducts when they fail to completely regress dur-
ing the development of the female urogenital system [3].
GDCs are usually located along the anterolateral vaginal wall
as this location reflects the mesonephric remnants left behind
during embryonic development that comprise the Gartner duct
[3, 4]. As a result, GDC can present as a palpable anterior

vaginal mass on physical examination [3, 5]. Though most
GDCs are small and asymptomatic, some can occasionally
enlarge to a degree where they may be confused for other
abnormalities such as a cystocele, Bartholin gland cyst, or
urethral diverticulum [1]. GDC may easily be misdiagnosed
as ectopic ureteroceles and subsequently treated as such. The
differential diagnosis for GDC includes urethral diverticulum,
Skene’s gland cyst or abscess, uterine prolapse, leiomyomata,
ectopic ureterocele, cystocele, endometriosis, and malignancy,
among others [1]. Ultimately, histologic findings of cuboidal
or low columnar, nonciliated, nonmucinous cells are required
for definitive diagnosis of GDC [6].
When the cysts are large, patients may describe symptoms
including mild discomfort, vaginal pressure, dyspareunia, in-
continence, or obstructive voiding issues. A thorough workup
is indicated prior to proceeding with surgical intervention as
several studies have shown that GDCs are often associated
with congenital malformations of the urinary tract. Cases of
ectopic ureter, unilateral renal agenesis, and renal hypoplasia
have been reported in association with GDC [3, 7–10]. Thus,
radiologic evaluation is warranted prior to excision of a vag-
inal wall mass to exclude any undiscovered urinary tract ab-
normalities. While these abnormalities typically present in
childhood, knowledge of their association with GDC can alert
clinicians to evaluate the urinary tract with imaging and plan
the surgical approach appropriately. The purpose of this re-
view is to examine the current methods of surgical manage-
ment of GDC to better inform the clinician. Furthermore, a
novel technique to facilitate the excision of GDC is presented.
Materials and methods
We conducted a PubMed search for English-language articles
with the human filter without a defined time range. The search
combined subject headings, title, abstract, and text words for
Gartner’s duct cysts, Gartner’s duct cyst, Gartner’s cysts,
Gartner’s cyst, Gartner duct cysts, Gartner duct cyst, Gartner
cysts, and Gartner cyst. A total of 267 articles were reviewed
by a single reviewer (R.D.) for inclusion in the study. Articles
that necessitated surgical management of GDC were included
if they met the criteria. Articles were excluded for the follow-
ing reasons: inadequate or unclear diagnosis of GDC, abscess
formation in GDC, nonsurgical management of GDC, article
unavailable for interlibrary loan, and language other than
English (Fig. 1). Articles which describe diagnosis with abso-
lute certainty but without histologic diagnosis (definitive di-
agnosis) were included, though if there was any question of
alternative diagnosis, these articles were excluded. Duplicate
patients published in multiple articles were also accounted for
and only included in the review once. Specific article exclu-
sion by reason was not included due to the non-relevance to
Int Urogynecol J
the methodology and study aims, as well as the broad variety
of exclusionary reasons per article.
Role of fluorescein dye
A novel technique utilizing fluorescein dye during excision of
GDC is intended to help better delineate the cyst walls and
potential tracts/extensions that are not easily identifiable, thereby
facilitating complete excision of GDC. Preoperative workup in-
cluding history and physical, imaging modalities including but
not limited to transvaginal ultrasound, CT urography, and MRI,
examination under anesthesia, and cystoscopy are still prudent
to ensure no communication exists between the cysts and the
urinary system. Often, cysts are discovered simply on physical
exam (Fig. 2). Intracyst injection of fluorescein dye followed by
cystoscopic evaluation can help confirm lack of urinary tract
involvement with the cyst in certain cases. The fluorescein dye
generates wall coloration, which helped identify the cyst edges,
making complete dissection of the cyst from the surrounding
tissue much easier. From the reviewer’s experience, this appears
to be useful in both cases when the cyst is intact or ruptured.
Results
Of the 267 articles reviewed, 34 were eligible for inclusion.
Table 1 represents a summary analysis of the outcome of this
review, while Table 2 shows the complete data set. Cyst exci-
sion was the most common surgical technique used (54%) with
other techniques found to be less common: tetracycline injec-
tion following aspiration of the cyst (16%), marsupialization
(15%), unroofing/partial excision (10%), and puncture/
evacuation (4%). One patient underwent uncomplicated fluo-
rescein dye-assisted cyst excision with no recurrence in her
most recent follow-up 30 months post-operation.
The average follow-up period after surgery per patient was
20.8 months, while the average period per article reviewed
(only one article suggested multiple patient follow-up) was
17.5 months. It is worth noting that in all of the articles
reviewed, there was only one case of postoperative complica-
tion (Table 2) [29]. In this particular case, the patient had un-
dergone marsupialization and was readmitted twice over the
next 2 months, ultimately having sepsis. The site of sepsis could
not be confirmed as the cyst was draining freely with no
reaccumulation of fluid. Eventual excision of the associated
ectopic ureter was performed, and the patient experienced no
further septic episodes [29]. Recurrence, though rare, occurred
most commonly with the cyst puncture and drainage technique
at a rate of 25% of the procedures published. This recurrence
was treated thereafter successfully with cyst excision [13].
Concomitant genitourinary malformations were found in 19
of the 92 (21%) surgically managed patients described in this
article. The diagnostic modalities utilized to discover the
Int Urogynecol J

Fig. 1 Flowchart of the inclusion

of articles in this study 267 Articles identified via
PubMed with “human” filter
64 non-English articles
excluded
203 English articles
remaining
165 articles excluded due to
nonsurgical management,
inability to obtain/review, or
GDC diagnosis unclear
38 Articles remaining
4 articles excluded due
to abcess formation
within GDC

34 articles included in review

genitourinary malformations included intravenous pyelograms,
voiding cystourethrograms, cystoscopies, CT, and MRI. When
a possible ectopic ureter is in question, one study demonstrated
that CT scan with delayed imaging was the most sensitive and
readily available modality [44]. When malformations were
present, partial excision was the most commonly used method,
followed closely by marsupialization.
Discussion
This review aims to provide a comprehensive review on the
surgical management of GDC along with presenting a new
technique using fluorescein dye to help delineate GDC walls
and facilitate complete cyst excision. The review demonstrated
that while most GDCs are benign and the majority of these
cysts are small and asymptomatic, patients with large and
symptomatic cysts may benefit from surgical management to
alleviate symptoms of persistent pain and discomfort due to
mass compression [35]. The important component in manage-
ment is to ensure the absence of involvement with the urinary
tract. While there are many case reports detailing surgical man-
agement of GDC, the current review revealed that there is no
standard technique to confirm the absence of urologic involve-
ment or to surgically manage an isolated Gartner’s duct cyst.
The studies and case reports examined utilized an array of
diagnostic modalities including intravenous pyelograms,
voiding cystourethrograms, cystoscopies, CT, and MRI.
Furthermore, there is a scarcity of literature documenting
how GDC should be surgically treated.

Fig. 2 Photograph of our

patient’s Gartner’s duct cyst. (i)
Smaller Gartner’s duct cyst in our
patient prior to excision. (ii)
Larger Gartner’s duct cyst in our
patient prior to excision. Note or-
igin in anterolateral vaginal wall
for both cysts

Table 1 Summary of surgical management of Gartner’s duct cysts
Surgical method Number Number of GU
of patients malformations
Excision 50 3 47.4
Marsupialization 14 6 33.9
Tetracycline injection following aspiration 15 0 4.5
Cyst unroofing/partial excision 9 8
Cyst puncture and drainage/ evacuation 4 2
Total: 92 19
Source: PubMed 2.26.2019
The current review demonstrates that in addition to the
history and physical, radiologic evaluation is crucial in
establishing the diagnosis of GDC. CT scan, ultrasound,
MRI, voiding cystogram, vaginogram, and renogram have
been used to aid diagnosis. Initial imaging with ultra-
sound is reasonable as it can effectively identify cysts,
assess vascularity, and evaluate whether nearby organs,
such as bowel or bladder, are involved. In addition, ultra-
sound can evaluate the size and shape of pelvic organs to
rule out associated urinary tract malformations. Once a
cyst has been identified, CT scan with delayed phases is
an economic, sensitive, and readily available option to
characterize the cyst; CT can also rule out a variety of
concomitant suspected genitourinary malformations [44].
GDC can be confirmed by direct cyst puncture and injec-
tion of contrast medium, which may also help demon-
strate a communication with the genital tract [26].
Cystoscopy with retrograde pyelography and direct lapa-
roscopy have been utilized to define the anatomy of the
reno-ureteral system and to confirm the presence of ure-
teric ectopy and are sensible approaches in patients with
radiologic evidence of GDC associated with genitourinary
abnormalities [26, 27].
Much of the literature available involves patients with con-
genital abnormalities of the genitourinary tract. Currarino re-
ported on five young females with a single vaginal ectopic
ureter via a dilated or cystic Gartner’s duct associated with
hypoplasia and dysplasia of the ipsilateral kidney [7]. Sheih
et al. described a girl with unilateral renal hypoplasia, ipsilat-
eral Gartner’s duct cyst, and ipsilateral imperforate hemi-va-
gina. In another study of 280,000 children with renal ultrason-
ic mass screening, 13 cases of cystic dilations in the pelvis
with ipsilateral renal agenesis or dysplasia were found. Seven
of these 13 cases were young females with GDC [8, 10].
Finally, Gotoh and Koyanagi reported on six cases of single
ectopic ureters opening into GDC [9]. Unrecognized presence
of urinary system involvement may lead to unintended conse-
quences such as urinary incontinence, fistula formation, and
renal damage.
Int Urogynecol J
Mean follow-up per Mean follow-up per Complications Number of
patient (months) article (months) recurrences
25.3 0 4
39.6 1 1
4.5 0 0
14 14 0 0
4.25 4.25 0 1
20.81 17.53 1 6
Surgical management of Gartner’s duct cysts
The current review demonstrates that surgical removal of
large, isolated, symptomatic GDCs can be achieved using
several techniques (Fig. 1). Surgical excision and cyst
marsupialization are the two most common methods for sur-
gical management of GDC. Cope et al. provide the largest
retrospective study of excision, which provides excellent evi-
dence for minimal recurrence (1 of 26 patients) when per-
formed properly [14]. Excision of the intact cyst is ideal, al-
though often not reasonably possible. In surgical excision,
sharp and blunt dissections are used to delineate the cyst from
the vaginal wall with counter traction placed on the surround-
ing tissues. The key to this type of dissection is surgical ac-
cessibility as well as the ability to delineate the cystic struc-
ture’s limits. In performing this technique, some authors report
mechanical rupturing of the cyst immediately prior to excision
may simplify the identification of the entire cyst wall when
traction is applied to the edges of the opening [24]. When
utilizing the marsupialization technique, a slit incision is first
made into the cyst followed by suturing the edges of the slit to
create a surface that is continuous from the exterior to the
interior of the cyst. Similar to Bartholin cyst marsupialization,
the internal edges are everted outwards, if possible. This tech-
nique allows the site to remain open and drain freely [16].
Finally, Atta and Abd-Rabbo described a more conservative
method for management of vaginal and vulvar GDC using
aspiration and tetracycline sclerotherapy. The cysts were sub-
jected to cyst fluid aspiration and 5% tetracycline injection of
a similar volume under local analgesia, followed by re-
aspiration of the injected tetracycline 24 h later until the cyst
walls collapsed. This technique was found to be successful in
a series of 15 patients who had no coexisting genitourinary
malformations [34].
A novel technique demonstrated that injection of fluoresce-
in dye is an easy way to support the radiologic findings that
GDCs are separate from the urinary system when utilized con-
currently with cystoscopy. In certain circumstances, such as
when an ectopic ureter is present that does not communicate
Int Urogynecol J

Table 2 Cases of surgical management in patients with Gartner’s duct cysts

Technique Reference Number Genitourinary Follow-up period Recurrence

of patients malformations (months)

Cyst excision Akkawi et al. [11] 1 No Unknown Unknown

Bala et al. [12] 1 No Unknown Unknown
Boujenah et al. [13] (after recurrence) 1a No 3 No
Cope et al. [14] 26 Unknown Median 82 1 patient
Davidson et al. [15] 1 No Unknown No
Dwyer and Rosamilia [3] 2 Yes 72 No
Emmons and Petty (case 2) [16] 1 No Unknown Yes
Hoogendam and Smink [17] 1 No 1.5 No
Kruse et al. [18] 1 No 1.5 No
Liachi et al. [19] 5 Unknown Unknown 2
Molina Escudero et al. [20] 4 No Unknown No
Our case (data not published) 1 No 30 No
Radman [21] 1 No Unknown No
Sumfest [22] (Case 3) 1 Yes Unknown No
Vlahovic et al. [23] 1 No 0.25 No
Wai et al. [24] 1 No 12 No
Zuker [25] 1 No Unknown Unknown
Marsupialization Binsaleh et al. [26] 2 Yes 72 No
Castagnetti et al. [27] 1 No 16 No
Cope et al. [14] 3 Unknown Median 82 No
Emmons and Petty (case 1) [16] 1 No Unknown Yes
Gadbois and Duckett [28] 1 Yes Unknown Unknown
Holmes et al. [29] 1b Yes 2 No
Inocencio et al. [30] 1 No 6 No
Letizia and Kelly [31] 1c No Unknown Unknown
Muram et al. [32] 1 Yes 60 No
Paraira et al. [33] 1 No Unknown Unknown
Sumfest [22] (case 1) 1 Yes Unknown No
Tetracycline injection following aspiration Abd-Rabbo and Atta [34] 15 No 3–6 (4.5) No
Cyst unroofing/partial excision Ohya et al. [35] 1 Yes 14 No
Sheih et al. [36–39, 45] 5 Yes Unknown No
Sumfest [22] (case 2) 1 Yes Unknown No
Tiwari et al. [40] (case 1) 1 No Unknown No
Watanabe et al. [41] 1 Yes Unknown Unknown
Cyst puncture and drainage/evacuation Boujenah et al. [13] 1a No 6 Yes
Fan et al. [42] 1 No 2.5 No
Rademaker [43] 1 Yes Unknown Unknown
Tiwari et al. [40] (case 2) 1 Yes Unknown Unknown

Legend:
a
One patient who underwent excision because of recurrence after cyst puncture and drainage
b
Patient experienced complication of postoperative sepsis
c
Unknown if patient experienced postoperative complication. Source: PubMed 2.26.2019

with the bladder or urethra, injection of fluorescein dye may demonstrated that GDCs are often associated with congenital
not exclude involvement of the urinary tract. This further high- malformations of the urinary tract such as ectopic ureter, uni-
lights the importance of a thorough workup with imaging prior lateral renal agenesis, and renal hypoplasia [7–10]. Excluding
to surgical intervention given that studies and case reports have these possibilities is important to assure the proper surgical

approach. Fluorescein dye was chosen because of its potent
coloring ability and lack of significant side effects. The color-
ing properties of fluorescein dye allow the surgeon to highlight
the cyst shelling, easing the process of extraction without
sacrificing precision. When the technique of mechanical rup-
turing of the cyst prior to excision is applied, the surgeon is still
using the edges of the opening to identify the cyst wall tissue in
order to help identify the entire cyst wall once traction is ap-
plied to it. It was demonstrated that fluorescein dye can facil-
itate the excision process of both a ruptured cyst and an intact
cyst. When excising a cyst that is advertently or inadvertently
ruptured, the fluorescein dye facilitates dissection by highlight-
ing the shelling of the cyst to be surgically removed. Similarly,
when dissecting an intact cyst, the cyst shelling is easily iden-
tified against a background of undyed normal tissue, making
complete excision much more likely.
Strengths and limitations
Due to the scarcity of literature on GDC, it may not be easy to
generalize the findings. To mitigate this problem, no defined
time range was set so as to increase the sample size from a
patient and publication standpoint. The publication dates of the
articles span from 1966 through 2018. While significant ad-
vances have taken place in imaging technology, surgical tech-
niques have largely remained the same over time. It should be
noted, however, that selection bias may be present in this study
because many authors who diagnosed GDC did not include
histologic analysis, which serves asthe definitive diagnosis of
GDC. While the current review was stringent in the article
selection process, there is always the possibility of both
under- and over-exclusion of gray literature. PubMed was the
only database utilized in this review as it had the most available
relevant articles. Other databases were not pursued because of
the low yield on the initial search. The percentage of GU
malformations present with GDC is likely over-represented
compared with the general population of patients with GDC
due to both the increased need for surgical management with
these malformations and the increased chance of publication
based on the novelty of these patients. This was partially tem-
pered by inclusion of retrospective chart review articles in this
study, which include all surgically managed GDCs per cohort
[14, 34]. Despite the limitations described above, this study
shows significant strength in addressing the major question
of the review, which aimed to highlight the most common
surgical techniques for GDC and their associated outcomes.
Conclusion
The most common technique for surgical management of
GDC is excision. It is crucial to ensure the absence of urinary
system involvement prior to surgical intervention as failure to
Int Urogynecol J
do so may lead to significant morbidity. A new technique
utilizing injection of fluorescein dye demonstrates that it is
an efficient method to simultaneously assess for Gartner’s
duct cyst communication with the urinary system and facili-
tate surgical excision by improving the delineation between
the cyst wall and normal vaginal tissue. More studies are
needed to verify whether fluorescein dye can persistently en-
hance visualization of the cyst wall and thus prevent recur-
rence by complete cyst wall excision.
Compliance with ethical standards
Conflicts of interest None.
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