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

Laparoscopic uterovaginal/vestibular anastomosis proves to be an effective and safe conservative treatment of cervical atresia associated with partial or total vaginal agenesis.
Conservative surgical repair in cervical atresia associated with partial or complete absence of the vagina
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VOLUME 118, ISSUE 3, P593-595

Authors:

Luigi Fedele, M.D. , Paolo Vercellini, M.D., Nevio Ciappina, M.D., Stefano Salvatore, M.D., Francesco Fedele, M.D., Massimo Candiani, M.D.

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.

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Go to the profile of Pedro Acien
4 months ago

I have read with interest the article “Conservative surgical repair in cervical atresia associated with partial or complete absence of the vagina” by Fedele et al [1] and have also watched the attached video. I believe that both things (article and video) are probably inappropriate, and, in my opinion, it would be too risky conclude that “Laparoscopic-assisted uterovaginal/vestibular anastomosis may be considered the treatment of choice”. I would highlight the following points:

  1. There is no mention of associated anomalies or the need for their investigation in their three patients who are 14, 12 and 13 years old, especially when the latter two cases also had a unicornuate uterus together with cervico-vaginal atresia. Did they also have renal agenesis and dysplasia?
  2. It seems to me that the techniques described in text and showed in the video are inadequate, both in laparoscopy (uterine perforation, fundus hysterotomy) and vaginally (H Incision, “the edges of the uterine cavity were then anastomozed with the edges of the hymenal incision”).
  3. If there was cervical atresia, where was the “natural mucus” produced? What do you mean by "no stenosis of the neocervix was recorded"?
  4. As they did not use molds or prostheses and given the age of the patients (12-14 years), how did they maintain the neovagina functional? Did they have regular sexual activity?.

These comments are based on our clinical experience and on the cases and articles that I am citing in references [2-6].

Pedro Acién, MD, PhD, Emeritus Professor. Miguel Hernandez University, Campus of San Juan, Alicante, Spain. Email: acien@umh.es

References:

  1. Fedele L et al. Conservative surgical repair in cervical atresia associated with partial or complete absence of the vagina. Fertil Steril 2022, article in press
  2. Acién P et al. Cervicovaginal agenesis: spontaneous gestation at term after previous reimplantation of the uterine corpus in a neovagina. Hum Reprod 2008;23:548-553.
  3. Acién P et al. Unilateral cervico-vaginal atresia with ipsilateral renal agenesis. Eur J Obtet Gynecol Reprod Biol 2004;117:249-251.
  4. Acién P, Acién M. Malformations of the female genital tract and embryological bases. Current Women´s Health Reviews 2007;3:248-288.
  5. Acién P, Acién M. The presentation and management of complex female genital malformations. Hum Reprod Update 2016;22/1:48-69.
  6. Acién P et al. Clinical pilot study to evaluate the neovaginal PACIENA prosthesis® for vaginoplasty without skin grafts in women with vaginal agenesis. BMC Women's Health 2019;19:144. https://doi.org/10.1186/s12905-019-0841-z.