A case of neovagina surgical creation using the uterine cervix remnant in a patient with Mayer-Rokitansky-Küster-Hauser syndrome

In this video article, a case of vaginoplasty using the uterine cervix in a patient with vaginal aplasia is shown. This could be a feasible technique in patients with a significantly distended uterine cervix.
A case of neovagina surgical creation using the uterine cervix remnant in a patient with Mayer-Rokitansky-Küster-Hauser syndrome

VOLUME 116, ISSUE 5, P1420-1422

Authors:

Mykhailo Medvediev, M.D., Ph.D., Dmytro Spesyvtsev, M.D., Dar'ya Pokrovenko, M.D.

Abstract:

Objective

To study the efficacy of a novel approach to vaginoplasty in a patient with vaginal aplasia and a preserved cervix.


Design

We present the case of a 28-year-old patient who was referred with a history of absent menstruation and vaginal intercourse was absent as well as abnormal development of the internal genitals. The patient underwent a laparoscopic cystectomy in 2012 because of an ovarian cyst and later that year underwent laparotomic supracervical hysterectomy with bilateral salpingectomy because of severe pain caused by a hematometra in their uterine remnant. In the period from 2013 to 2016, multiple pelvic ultrasound examinations revealed a fluid structure in the pelvis. By 2020, the size of the lesion had increased to 10 cm on average. A computed tomography scan and magnetic resonance imaging showed a mucinous lesion in the lower part of the patient’s pelvis resembling the cervical origin. No pathology of the urinary tract was found. A laparoscopic approach was chosen to achieve the two main goals of the patient—the possibility of vaginal intercourse and the treatment of the intraabdominal lesion. The procedure started with a vaginal step when the neovagina dissection was performed as in the classical Davydov technique up to the beginning of the dilated cervical remnant. Bilateral ureterolysis was performed laparoscopically to prevent ureteral injury. The peritoneum was widely dissected from both the anterior and posterior surfaces of the uterine cervix, which appeared as a large structure filled with typical cervical mucus. Partial dissection of the sacrouterine and ovarian ligaments on both sides was performed to mobilize the cervix. A transverse incision of the cystically dilated cervix in the cranial part was performed and the edges of the incision were brought down to the introitus of the vagina. The cervicovulvar anastomosis was fixed by separate sutures with Vicryl 2-0.


Setting

The surgery was performed in an inpatient setting equipped with conventional laparoscopic instruments, a 30-degree laparoscope, a high-definition video system, xenon light source, insufflator, irrigator, and bipolar and monopolar energy sources.


Patient(s)

A single patient, mentioned previously.


Intervention(s)

Surgical vaginoplasty using the preserved cervix. The details are explained in the Design section.


Main Outcome Measure(s)

Restoration of the normal vaginal anatomy and function.


Result(s)

In the postoperative period, the patient did not have any postoperative complications. The urinary catheter was removed on the first postoperative day. From day 1, the patient was taught to make daily vaginal dilations with a vaginal dilator to maintain normal vaginal depth and width. The patient was discharged on day 3 after surgery. In a 3-month follow-up visit, the patient's vagina appeared normal in size with transverse folds and was very well lubricated because of the natural secretions of the cervical mucosa. The patient had been sexually active by the time of the follow-up visit.


Conclusion(s)

According to a literature search, this was the first published case of a successful neovagina creation through cervicovulvar anastomosis. Although different surgical approaches were widely discussed in previous publications of Fertility and Sterility, such as “Laparoscopic uterovaginal anastomosis in Mayer-Rokitansky-Küster-Hauser syndrome with functioning horn”, “Laparoscopy-assisted Ruge procedure for the creation of a neovagina in a patient with Mayer-Rokitansky-Küster-Hauser syndrome”, and “Evaluation of amnion in creation of neovagina in women with Mayer-Rokitansky-Küster-Hauser syndrome”, which were all variants of vaginoplasty with allograft, vaginal distention (Vecchietti procedure), or the use of native tissues (Davydov technique), our approach could be more feasible in the rare cases of preserved distended cervix because of less induced trauma when compared with that of cervical removal. This is because of the strong and lubricated nature of the cervical epithelium, which is already present and does not require time for epithelization.

Comments

Go to the profile of Pedro Acien
6 months ago

Comment for F&S-Dialog: https://www.fertstertdialog.com/posts/31809

Medvediev M et al. A case of neovagina surgical creation using the uterine cervix remnant in a patient with Mayer-Rokitansky-Küster-Hauser syndrome. Fertil Steril 2021;116/5:1420-22.

Dear authors, in our opinion the reported case is not a Rokitansky or MRKH syndrome. In Rokitansky syndrome there is a complete utero-vaginal agenesis although bilateral Müllerian remnants that may eventually contain a functional endometrium might be present. Such anomaly corresponds to group I of the ASRM classification-2021 (1). Whereas, it seems clear that this patient had a congenital cervico-vaginal atresia or agenesis with a present and functional uterine body and normal tubes. The cervical agenesis seems to have been distal and the patient had previously undergone a subtotal (supracervical) hysterectomy due to pain and hematometra, leaving the cervical canal in which a mucinous cyst was later formed and that thereafter served to cover the neovagina (2). So the reported case, should be classified in group II.

Additionally, we support that it is not necessary to perform hysterectomy in cases of cervico-vaginal agenesis with a normal functional uterine body. Utero-neovaginal anastomosis can be done as can be seen in (3) and some other reports, with "good" results and retaining patient´s capability for conception.

Finally, neovagina can also be done following the McIndoe technique and the use of a PLA prosthesis without the need of skin graft (4,5).

Pedro Acién, M.D., Ph.D., Emeritus Professor. Department of Gynecology, Miguel Hernandez University of Elche, San Juan Campus, Alicante, Spain.

Maribel Acién, MD, PhD. Chief of Gynecology Section, San Juan University Hospital. Associate Professor. Department of Gynecology, Miguel Hernandez University of Elche, San Juan Campus, Alicante, Spain.

References:

1. Pfeifer SM, Attaran M, Goldstein J, et al. ASRM müllerian anomalies classification 2021. Fertil Steril 2021;116/5:1238-1252.

2. Medvediev M, Spesyvtsev D, Pokrovenko D. A case of neovagina surgical creation using the uterine cervix remnant in a patient with Mayer-Rokitansky-Küster-Hauser syndrome. Fertil Steril 2021;116/5:1420-22.

3. Acién P, Acién MI, Quereda F, Santoyo T. Cervicovaginal agenesis: spontaneous gestation at term after previous reimplantation of the uterine corpus in a neovagina: Case Report. Hum Reprod 2008;23/3:548-553.

4. Acién P, Acién M, Oliva-Meyer MA, Sánchez-Lozano M, Martínez-Garcia J. McIndoe Operation without Skin Graft: A New Neovaginal Prosthesis of Polylactic Acid (PLA). British Journal of Medicine & Medical Research 2016;18(9):1-7.

5. Acién P, Nohales F, Sánchez-Ferrer ML, Sánchez-Lozano M, Navarro-Lillo V, Acién MI. Clinical Pilot Study to Evaluate the Neovaginal PACIENA Prosthesis® for Vaginoplasty without Skin Graft in Women with Vaginal Agenesis. BMC Women´s Health, 2019, Nov 26;19(1):144.