Conservative surgical repair in cervical atresia associated with partial or complete absence of the vagina

Fertil Steril. 2022 Sep;118(3):593-595. doi: 10.1016/j.fertnstert.2022.05.035. Epub 2022 Jul 9.

Abstract

Objective: To describe the surgical technique of laparoscopically assisted uterovaginal/vestibular anastomosis in patients with cervical atresia associated with partial or complete absence of the vagina.

Design: Surgical video article. Local institutional review board approval and written permission from the patients were obtained.

Setting: Tertiary referral center.

Patient(s): The surgical video presents surgical correction in 3 different patients with cervical agenesis. The first patient, aged 14 years, had a normoconformed uterus and total absence of the vagina. The second patient, aged 12 years, demonstrated a left unicornuate uterus and partial absence of the vagina. The third patient, aged 13 years, displayed a right unicornuate uterus and total absence of the vagina.

Intervention(s): Laparoscopic time and perineal time. During laparoscopy, the entire abdominopelvic cavity was assessed to evaluate the uterine morphology and size to exclude anomalies such as hematometra. The adnexa and adhesions were evaluated and any endometrial flare-ups were treated appropriately. A laparoscopic ultrasound probe was used to evaluate the size and location of the endometrial cavity. In cases with total absence of vaginas, an H-shaped incision in the hymenal dimple allowed a larger area of available tissue for the anastomosis. A tunnel was then created by blunt finger dissection between the bladder and rectum. Simultaneously, the uterus was pushed caudally by an assistant while the operator grasped it from below using an internal probe. A circular myometrial incision at the uterine caudal body allowed to reach the endometrial cavity and open it. The edges of the uterine cavity were then anastomized with the edges of the hymenal incision. In cases with partial absence of vaginas, the creation of the tunnel between the vagina and rectum was not necessary and the open uterus was anastomosed with the margins of the vaginal dome, engraved on the guide of a metal dilator. All patients received broad-spectrum antibiotics (i.e., cephalosporins of the last available generation) on the day before surgery and on the day of surgery.

Main outcome measure(s): Intraoperative anatomic and ultrasound data, neovaginal length, and recovery of menstrual function 180 days after surgery.

Result(s): The surgical procedure was successful in all cases. No major complications were recorded, and in particular, no bladder or rectal injuries occurred. No stenosis of the neocervix was recorded. The main hospital stay of the patients was 3.5 ± 1.5 days. In each case, the neovagina developed gradually over time after surgery because of the upward traction action exerted by the uterus through its natural ligament apparatus (cardinal ligaments and ovarian vessels). This fact eliminated the requirement for the use of a mold after surgery. At the 15-week follow-up, vaginoscopy was performed, with mucus observed at the site of uterovaginal anastomosis in all cases. None of the patients developed infection after surgery because of the avoidance of molds or pessaries and the natural mucus production. Six months after surgery, the length of the neovagina was >4 cm in all 3 cases.

Conclusion(s): Laparoscopic-assisted uterovaginal/vestibular anastomosis may be considered the treatment of choice for patients with cervical atresia associated with partial or complete absence of the vagina.

Keywords: Cervicovaginal atresia; müllerian anomalies; unicornuate uterus; uterovestibular anastomosis.

MeSH terms

  • Anti-Bacterial Agents
  • Cephalosporins
  • Cervix Uteri / abnormalities
  • Cervix Uteri / diagnostic imaging
  • Cervix Uteri / surgery
  • Female
  • Humans
  • Laparoscopy* / adverse effects
  • Laparoscopy* / methods
  • Urogenital Abnormalities
  • Uterine Cervical Diseases* / surgery
  • Uterus / abnormalities
  • Uterus / surgery
  • Vagina / abnormalities
  • Vagina / diagnostic imaging
  • Vagina / surgery

Substances

  • Anti-Bacterial Agents
  • Cephalosporins

Supplementary concepts

  • Uterine Anomalies