Sonography in the surgical management of vaginal and cervical atresia

Cervicovaginal atresia with hematometra: restoring menstrual and sexual function by utero-coloneovaginoplasty

BACKGROUND

Cervicovaginal atresia is a rare Mullerian anomaly. The management of cervicovaginal atresia has evolved from historical recommendations of hysterectomy to various reconstructive procedures more recently. The latter carries a risk of significant morbidity and unknown fertility. We present our experience in the management of this complex anomaly.

METHODS

Twenty patients with cervicovaginal atresia were operated in our hospital from January 2004 through December 2013. The details of their anatomical variations and functional outcomes were analyzed.

RESULTS

Eighteen out of twenty patients had cervical agenesis. Two patients had cervical hypoplasia. All patients underwent utero-coloneovaginoplasty. Post operatively, all patients have regular menstrual cycles. One patient is married, sexually active and has satisfactory coital function. One patient had a bowel anastomotic leak that required a diversion ileostomy. Two patients developed mild stenosis. One patient has mild neovaginal mucosal prolapse. No patient has developed pyometra.

CONCLUSION

Patients with cervicovaginal atresia need to be counselled about the various reconstructive options available and the potential risks. Social and economic factor play a significant role in determining the plan of management. For patients from conservative societies, utero-coloneovaginoplasty provides a safe conduit for the passage of menstrual flow and coitus, at the cost of permanent infertility.

A new approach in the management of lower Mullerian atresia

Over the past 20 years we have encountered 13 cases of lower genital tract atresia or obstruction. There were eight cases due to a high transverse vaginal septum. These were dealt with by standard surgical reconstruction. One later recurred and required hysterectomy. Five patients presented with cervical atresia. These were successfully treated by a new abdomino/vaginal approach. All menstruated normally after the procedure and one became pregnant and delivered a normal baby by caesarean section at term. None of the cases had recurrent obstruction and none required hysterectomy.

Role of new sono-imaging technique 'sonocolpography' in the diagnosis and treatment of the complete transverse vaginal septum and other allied conditions

OBJECTIVE

To evaluate the value of a newly suggested ultrasonographic technique 'Sonocolpography' in diagnosing the complete transverse vaginal septum and other allied conditions and planning their treatment.

SUBJECTS AND METHODS

Ten cases of complete vaginal septum, eight cases of atresia and four cases of vaginal aplasia seen at Kasr El Aini School of Medicine, Cairo University were selected for this study. Sonocolpography is done using a vaginal balloon and transabdominal ultrasonography. The efficacy of the latter is assessed in comparison to the conventional transabdominal technique. The different sonographic criteria in the conventional technique and in sonocolpography were determined for the studied cases. A cross-over test was also suggested for anticipating the needed surgery. This is done by pushing the balloon maximally inward and determining the ability of the echoes of the vaginal pouch to accommodate the balloon to stretch and to cross over the defect, in turn determining the needed surgery.

RESULTS

Improved ultrasonographic images were successfully obtained for all cases studied. The diagnostic accuracy for these cases was 95.5% for septa, 86.4% for atresia and 90.9% for aplasia. The corresponding figures for the conventional techniques were 54.5, 68.2 and 77.2%, respectively. Sonocolpography was more sensitive and more specific for all cases studied compared to the conventional technique. Planning of the necessary surgery was successfully determined in 16 cases having positive cross-over tests, where excision and direct anastomosis were performed. Surgery planning was also successful in two cases having negative tests and four cases of invalid tests, where more extensive surgery was needed.

CONCLUSION

Sonocolpography is a new achievement that is essential for imaging cases of the complete vaginal septum and other allied conditions, and also in planning the associated treatment.

Congenital cervical atresia: report of seven cases and review of the literature

OBJECTIVE

Our aim was to evaluate the clinical course and management of congenital cervical atresia.

STUDY DESIGN

This retrospective analysis included 7 patients referred to our clinic and a review of the medical literature.

RESULTS

Including this case series, 58 cases of congenital cervical atresia have been reported in the literature. Forty-eight percent of patients had isolated congenital cervical atresia with a normal vagina whereas the remainder had either complete or partial vaginal atresia ("shortened blind vaginal pouches"). Surgical management has included abdominal hysterectomy or uterovaginal cannulation with or without vaginoplasty. In 59% of patients who underwent uterovaginal canalization procedures (23/39), normal menstrual bleeding was achieved. Four of these patients subsequently became pregnant and were delivered at term.

CONCLUSION

Surgical canalization in selected patients with congenital cervical atresia can be successfully performed to provide patients an opportunity for conservative management, resulting in normal menstrual bleeding, resolution of cyclic pelvic pain, and some potential (albeit limited) for fertility.

Congenital cervicovaginal aplasia with septate uterus and functioning endometrium

A 14-year-old adolescent girl presented with primary amenorrhea and uncontrolled pelvic pain. Evaluation using pelvic sonogram, magnetic resonance imaging, and laparoscopy confirmed the diagnosis of cervicovaginal aplasia with functioning endometrium and a vaginal fistulous tract. At age 19 years, hysterectomy and vaginoplasty allowed the patient to be free of pain and to have normal sexual function.

Ultrasound evaluation of female genital tract anomalies: a review of 64 cases

Sixty-four patients with an ultrasound diagnosis of an anomaly of the female genital tract were studied retrospectively to determine the accuracy and usefulness of sonographic examination of these anomalies in the pregnant (64%) and the nonpregnant (36%) patient. Ultrasound diagnoses in 46 patients with follow-up included: (1) bicornuate/septate uterus in 21 cases, (2) uterus didelphys in 18 cases, (3) cervical and vaginal atresia in three cases, (4) obstructed lower but normal upper genital tract in two cases, and (5) abnormal-appearing uterus in two cases. Ultrasound diagnosis was compared with hysterosalpingographic and/or surgical findings in 43 patients and with physical examination in three patients. Scan results were classified as diagnostic in 26%, confirmatory in 63%, and incorrect in 11%. Ultrasound is a reliable clinically useful method of studying genital tract anomalies in gynecologic patients.