Uterine conserving surgery in a case of cervicovaginal agenesis with unicornuate uterus

Could we preserve reproductive function in complete vaginal agenesis and cervical agenesis? A case report and clinical perspective

Early studies show hysterectomy is a main surgical choice for cervical agenesis with excellent outcomes. However, as time went on more literature showed successful uterovaginal anastomosis performed in cervical agenesis. This case report wishes to highlight the management of the patient with complete vaginal and cervical agenesis, which presented with acute abdominal pain due to severe extension of the uterus. We aim to explore options and dilemmas in preserving reproductive function in such cases. A 13-year-old child was presented with acute abdominal pain and primary amenorrhea due to suspected vaginal agenesis. Physical examination revealed fundal height equal to 20 weeks of pregnancy. The vagina has no introitus and the external urethral meatus was normal. Abdominal ultrasound revealed a hematometra with the size of 8.84 × 3.12 cm accompanied by hematosalpinx on both fallopian tubes. The patient then undergoes an emergency hysterectomy. During the operation, it was found the cervix was substituted with the muscular part of the uterus with a little part of connective tissue part with no cardinal ligaments. Earlier articles showed hysterectomy is the first line of treatment in cervical agenesis. However, with the advancement of surgical techniques conservative treatment was made possible and reported in several case reports. According to European Society of Human Reproduction and Embryology (ESHRE) classification, our patient is classified as U0-C4-V4 (complete vaginal and cervix agenesis). We opted for a hysterectomy in this patient due possibility of fertility being slim and acute abdominal pain relief. Performing such a difficult operation in our setting requires expert meetings, and tool preparation also an amniotic graft for neovagina which in our case we could not afford due to the acute abdominal pain the patient experienced, and the patient's adamant wish for a hysterectomy. Hysterectomy remains a safer approach in low-resource settings with excellent postoperative outcomes. However, reconstructive surgery is an option that should be offered with its own risks and benefits.

The Path of Birth is Not Always Normal: A Case Report of Cervicovaginal Agenesis

Cervical agenesis is a rare congenital Mullerian anomaly. Its association with vaginal agenesis is further rare, reported in 39% of cases of cervical agenesis. The conventional treatment for this condition was hysterectomy. However, with evolving surgical skills and assisted reproductive techniques, conservative surgery could be considered as the first-line treatment in the current era. We report one such case of cervicovaginal agenesis in a 13-year-old adolescent girl managed successfully with cervicovaginoplasty. The patient was relieved of cyclical pain abdomen and resumed menstrual cycles postoperatively.

Clinical features of congenital complete vaginal atresia combined with cervical aplasia: A retrospective study of 19 patients and literature review

Congenital vaginal atresia is a rare congenital reproductive tract abnormality. To assess the clinical manifestations and feasibility of preserving uterus for congenital complete vaginal atresia with cervical aplasia, nineteen cases who underwent surgical treatment in West China Second Hospital of Sichuan University were retrospectively studied. The cervical status, clinical manifestations, the rate of vaginal re-stenosis and pelvic inflammation after surgery were assessed. Additional 101 similar cases searched through digital Pub Med were included to analyze the feasibility of preserving the uterus. Periodic abdominal pain, primary amenorrhea, and pelvic mass were the primary signs and symptoms. According to the magnetic resonance imaging (MRI), all the uterine cavities expanded, and the atresia sites were above the inner urethral orifice. Data of the cases preserving uteri from both our hospital and the literature showed the rate of re-stenosis in patients with external cervical obstruction was 15.9% while it was 40% in the other types of cervical aplasia (P = .026). The rate of recurrent pelvic inflammation and hysterectomy was 2.3% for cervical external os obstruction and 8% for the other cervical aplasia types(P = .296). In conclusion, vaginoplasty and cervicovaginal anastomosis could preserve the fertility for complete vaginal atresia with cervical external os obstruction.

Functional and Reproductive Outcomes Following Surgical Management of Congenital Anomalies of the Cervix: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to evaluate surgical treatment for malformations of the cervix in terms of short- and long-term postoperative function and relevant reproductive outcomes.

DATA SOURCES

International Prospective Register of Systematic Reviews (ID No CRD42019128899). Electronic databases were searched for eligible studies up to October 2019 on Medline/PubMed (1966-2019), Scopus/Elsevier (1950-2019), and Google Scholar (up to 2019). Search terms included "congenital cervical malformations/anomalies," "uterocervical aplasia/dysgenesis/agenesis," "cervical aplasia/dysgenesis/ agenesis," "müllerian anomalies/dysgenesis/agenesis," "utero-vaginal anastomosis," "cervical reconstruction," "uterocervical reconstruction/canalization," "cervical canalization," "reproductive/pregnancy/functional outcome," "menstruation," "pregnancy," and "regular periods."

METHODS OF STUDY SELECTION

Studies were chosen and included with clear description of preoperative diagnosis via sonography, magnetic resonance imaging, and surgical confirmation; assessment and clear description of gynecologic anatomy and any concomitant anomalies; meticulous description of the operative technique; follow-up of at least 6 weeks postoperatively; and postoperative end points including menstrual and reproductive outcomes. We included randomized controlled trials, case-control studies (both prospective and retrospective), and case reports. Data registries, studies without clearly described primary or secondary outcomes, and studies not in the English language were excluded from the analyses.

TABULATION, INTEGRATION, AND RESULTS

The literature search returned 745 studies; 546 records were initially excluded (397 not related to the topic, 15 not related to humans, 134 non-English language); 111 full-text articles were further excluded (patients underwent hysterectomy or no surgery); 88 studies with a total of 249 patients were suitable for analysis. Almost all patients had preoperative amenorrhea (248/249, 99.6%). Postoperatively, of 249 patients, resolution of menstruation occurred in 228 patients (91.6%), and hysterectomy was performed in 22 patients (8.8%); overall, there were 30 (12.0%) conceptions that resulted in 27 (10.8%) viable and 24 (9.6%) term pregnancies. Indications for hysterectomy were stenosis of the genital tract and sepsis. Coexisting vaginal agenesis and use of full thickness skin graft for creation of neocervix was associated with negative surgical outcomes.

CONCLUSION

This review suggests that conservative surgical approaches result in better clinical and reproductive outcomes than more aggressive reconstructive surgeries for patients with malformations of the cervix.