RESUMEN
OBJECTIVE: To discuss several techniques of hysteroscopic surgery for complete septate uterus. CASE REPORT: A 40-year-old female with unexplained primary infertility was diagnosed with complete septate uterus with septate cervix. Hysteroscopic incision of complete septate uterus was performed by using ballooning technique. The patient conceived naturally shortly after the operation and delivered a healthy, term infant. CONCLUSION: Hysteroscopic incision of complete septate uterus is a safe and prompt way of metroplasty. With the knowledge obtained from a pre-operative MRI, it can be completed without laparoscopy and the need for hospitalization.
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Cuello del Útero , Histeroscopía , Útero , Humanos , Femenino , Adulto , Histeroscopía/métodos , Embarazo , Cuello del Útero/anomalías , Cuello del Útero/cirugía , Útero/anomalías , Útero/cirugía , Infertilidad Femenina/cirugía , Infertilidad Femenina/etiología , Nacimiento a Término , Anomalías Urogenitales/cirugía , Anomalías Urogenitales/diagnóstico por imagen , Útero SeptadoAsunto(s)
Trastornos del Desarrollo Sexual 46, XX , Conductos Paramesonéfricos , Procedimientos de Cirugía Plástica , Útero , Humanos , Femenino , Embarazo , Trastornos del Desarrollo Sexual 46, XX/diagnóstico , Trastornos del Desarrollo Sexual 46, XX/terapia , Trastornos del Desarrollo Sexual 46, XX/cirugía , Conductos Paramesonéfricos/anomalías , Procedimientos de Cirugía Plástica/métodos , Útero/anomalías , Vagina/anomalías , Vagina/cirugía , Anomalías Congénitas/diagnóstico , Anomalías Congénitas/terapia , Anomalías Congénitas/cirugía , Fertilidad , Histerectomía , Genitales Femeninos/anomalías , Infertilidad Femenina/terapia , Infertilidad Femenina/diagnóstico , Infertilidad Femenina/etiología , Cuello del Útero/anomalías , Laparoscopía/métodosRESUMEN
Objective: To analyze the incidence and clinical phenotype of the concomitant extragenital malformations in the patients with female reproductive tract anomalies. Methods: A retrospective study was conducted using clinical data of hospitalized patients diagnosed with uterine, cervical, or vaginal malformations from January 2003 to December 2022 in Peking Union Medical College Hospital. The malformations were classified according to American Society for Reproductive Medicine müllerian anomalies classification 2021, and in each type, the incidence and specific manifestations of concomitant extragnital malformations were analyzed. Results: A total of 444 patients were included. The overall incidence of concomitant extragenital malformations was 43.5% (193/444), including urinary system, skeletal system, and other system malformations. Renal malformations on the obstructed side were present in all patients with oblique vaginal septum syndrome (100.0%, 78/78). The total incidence of concomitant extragnital malformations was as high as 8/11 in uterus didelphys, 43.5% (10/23) in unicornuate uterus, 33.6% (79/235) in Mayer-Rokitansky-Küster-Hauser syndrome, 18.8% (6/32) in septate uterus and 18.5% (12/65) in cervical agenesis. Urinary system malformations (30.6%, 136/444) and skeletal system malformations (13.5%, 60/444) were the most common concomitant malformations in all types, in which, unilateral renal agenesis and scoliosis were the most common. Conclusions: Urinary and skeletal system malformations are important features of female reproductive tract anomalies. Urologic ultrasonography and spinal roentgenogram are recommended for all patients with female reproductive tract anomalies.
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Anomalías Múltiples , Conductos Paramesonéfricos , Anomalías Urogenitales , Útero , Vagina , Humanos , Femenino , Estudios Retrospectivos , Anomalías Urogenitales/epidemiología , Útero/anomalías , Vagina/anomalías , Conductos Paramesonéfricos/anomalías , Incidencia , Anomalías Múltiples/epidemiología , Trastornos del Desarrollo Sexual 46, XX/epidemiología , Riñón/anomalías , Cuello del Útero/anomalías , Cuello del Útero/patología , Genitales Femeninos/anomalías , China/epidemiología , Anomalías Congénitas/epidemiología , AdultoAsunto(s)
Cerclaje Cervical , Procedimientos Quirúrgicos Robotizados , Incompetencia del Cuello del Útero , Útero , Adulto , Femenino , Humanos , Embarazo , Útero Bicorne , Cerclaje Cervical/métodos , Cuello del Útero/cirugía , Cuello del Útero/anomalías , Procedimientos Quirúrgicos Robotizados/métodos , Resultado del Tratamiento , Anomalías Urogenitales/cirugía , Anomalías Urogenitales/complicaciones , Incompetencia del Cuello del Útero/cirugía , Útero/cirugía , Útero/anomalíasRESUMEN
We report a rare case of a retroperitoneal uterus-like mass communicating with the endocervix, which presented as abdominal pain and bloating associated with severe irregular vaginal and postcoital bleeding. Our patient did not have any structural abnormalities of the urogenital system or otherwise, which makes a müllerian defect unlikely in our case. Based on the diagnostic criteria for the choristoma, that theory would be excluded here as the mass communicated with the endocervix. This strengthens the theory of metaplasia, under the effect of oestrogen and accelerated by the hyperoestrogenic state of pregnancy as the most likely postulate for our patient. Although the uterus-like mass is not commonly reported, it should be considered as a possible differential for pelvic masses.
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Cuello del Útero , Anomalías Urogenitales , Embarazo , Femenino , Humanos , Cuello del Útero/anomalías , Útero/diagnóstico por imagen , Útero/anomalías , Vagina/anomalías , Dolor Abdominal/complicaciones , Estrógenos , Anomalías Urogenitales/complicacionesRESUMEN
PURPOSE: To study the long-term results of utero-vaginal anastomosis in cases of cervical malformations. METHODS: This is a retrospective cohort study. Nine patients presented with cryptomenorrhea due to cervical malformations (5 patients with cervical agenesis and vaginal aplasia, 2 patients with cervical agenesis and upper vaginal aplasia, and two patients with cervical dysgenesis in form of cervical obstruction). Five patients had utero-vaginal anastomosis (UVA) with McIndoe vaginoplasty. Four patients had UVA without vaginoplasty. Follow-up was done by transabdominal and/or transvaginal ultrasound monthly for the first 3 months then every 6 months thereafter for a duration that ranged from 15 to 82 months. The main outcome measures are achieving menstruation, dysmenorrhea, pelvic inflammatory disease (PID), needed interventions after primary surgery, infertility, and pregnancy rate. RESULTS: Nine (100%) patients achieved menstruation, one (12%) experienced severe dysmenorrhea, two (22%) had PID, seven (78%) needed dilatation of the anastomosis site, three (33%) needed reoperation, nine (100%) had primary infertility, two (28.5%) achieved clinical pregnancy, and only one (14%) ended by live birth. CONCLUSION: Conservative surgery for cervical malformation is a promising choice for relieving the obstructive symptoms. Regular dilatation is recommended. Pregnancy is a remote hope that is hindered by many challenges.
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Cuello del Útero , Infertilidad , Embarazo , Femenino , Humanos , Estudios de Seguimiento , Cuello del Útero/cirugía , Cuello del Útero/anomalías , Dismenorrea/etiología , Dismenorrea/cirugía , Estudios Retrospectivos , Vagina/cirugía , Vagina/anomalías , Fertilidad , Anastomosis Quirúrgica/métodosRESUMEN
BACKGROUND: The surgical treatment of girls with cervical atresia and complete absence of the vagina remains a problem because of the rarity of cases and the controversial study results. OBJECTIVE: To describe the surgical technique and long-term results of laparoscopically assisted uterovestibular anastomosis in patients with cervical atresia and complete absence of the vagina STUDY DESIGN: Sixteen consecutive patients with cervical atresia and complete absence of the vagina were conservatively treated with laparoscopically assisted uterovestibular anastomosis in 2 tertiary care referral centers. The follow-up assessments included clinical examination, determination of the presence and quality of sexual intercourse, and vaginoscopy. RESULTS: All patients underwent laparoscopically assisted uterovestibular anastomosis. No perioperative complications occurred. The mean follow-up period was 8 ± 3.2 years. In all patients, the length of the neovagina was greater than 4 cm at 1 year after the surgery and approximately 6 cm after 2 years. After the start of sexual intercourse, the neovagina exceeded 7 cm in length in 2 of the 11 sexually active patients. At 12 months after the surgery, iodine-positive epithelium was present in all patients and was maintained over time. The continuity of the neovagina, neocervix, and uterine body was maintained without further interventions in 15 of the 16 patients. During the follow-up, 11 patients were sexually active, 5 were married, 4 were seeking conception, and 2 had spontaneous pregnancy. CONCLUSIONS: Laparoscopically assisted uterovestibular anastomosis seems to be a safe and effective treatment for patients with cervical atresia and complete absence of the vagina, at least in terms of the recovery of menstrual function and sexual activity.
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Cuello del Útero , Laparoscopía , Enfermedades del Cuello del Útero , Vagina , Enfermedades Vaginales , Femenino , Humanos , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Cuello del Útero/cirugía , Cuello del Útero/anomalías , Estudios de Seguimiento , Laparoscopía/métodos , Vagina/cirugía , Vagina/anomalías , Enfermedades del Cuello del Útero/congénito , Enfermedades del Cuello del Útero/cirugía , Enfermedades Vaginales/congénito , Enfermedades Vaginales/cirugíaRESUMEN
The authors discuss the incidence, the embryological development, the classification, the presentation and the treatment options of this rare reproductive tract abnormality. In the past, the treatment proposed almost unanimously was hysterectomy and subsequent construction, when necessary, of a neovagina. In recent decades, numerous experiences of conservative therapies have accumulated that allow the restoration of menstrual function and in some rare cases even the achievement of a pregnancy. However, complications associated with recanalization of the cervix frequently resulted in the need for repeated surgery, risk of serious and sometimes fatal ascending infection. This review aims to analyze the most recent and significant experiences of conservative surgery in this field to provide an accurate picture of the various techniques and their outcomes, especially from the point of view of fertility. Conservative surgery should now be considered as the first-line treatment option. On the other hand, it is not possible to draw conclusions on the superiority of one technique over another among the various conservative options. This would require large series with adequate follow-up, which unfortunately are not available.
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Anomalías Congénitas , Procedimientos de Cirugía Plástica , Cirugía Plástica , Neoplasias del Cuello Uterino , Embarazo , Femenino , Humanos , Cuello del Útero/cirugía , Cuello del Útero/anomalías , Neoplasias del Cuello Uterino/cirugía , Histerectomía , Vagina/cirugía , Anomalías Congénitas/cirugíaRESUMEN
BACKGROUND: Congenital cervicovaginal agenesis (CVA) with functioning endometrium is an extremely rare mullerian anomaly. Genital tract patency and fertility preservation are the major challenges in cases of CVA. With the advances in surgical techniques, management has shifted from a radical approach-like hysterectomy towards a more conservative approach of uterine conservation. CASE PRESENTATION AND REVIEW OF THE LITERATURE: In the present study, we report our experience in managing four cases of congenital CVA with complete vaginal atresia, which were treated with a simple minimally invasive vaginal approach for UVA without using graft for neovagina creation and studied the long-term anatomic and functional result of uterovestibular anastomosis (UVA) in patients with CVA. A literature review was performed for congenital complete vaginal atresia (≤ 2 cm blind vagina), with a functioning uterus. The experience and results of this 4-year study are in accordance with the prior studies with 97% (33/34) success rate, where vestibular mucosa was used for the UVA. CONCLUSIONS: Findings of this study should encourage more gynaecologists to learn and recreate a complete vaginal approach, as no special surgical equipments are needed. Hysterectomy should only be reserved for cases, where repeated anastomosis attempts fail. This minimally invasive technique should be preferred over canalization procedures and graft, as it is associated with a higher success rate with least complications and recurrence. Conservative end-to-end anastomosis with a completely vaginal approach should be offered as the primary treatment option for CVA with total vaginal atresia.
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Cuello del Útero , Útero , Femenino , Humanos , Cuello del Útero/cirugía , Cuello del Útero/anomalías , Útero/cirugía , Útero/anomalías , Vagina/cirugía , Vagina/anomalías , Anastomosis Quirúrgica/métodosAsunto(s)
Cuello del Útero , Cuello , Femenino , Humanos , Cuello del Útero/anomalías , Cuello/cirugíaRESUMEN
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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Laparoscopía , Enfermedades del Cuello del Útero , Antibacterianos , Cefalosporinas , Cuello del Útero/anomalías , Cuello del Útero/diagnóstico por imagen , Cuello del Útero/cirugía , Femenino , Humanos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Anomalías Urogenitales , Enfermedades del Cuello del Útero/cirugía , Útero/anomalías , Útero/cirugía , Vagina/anomalías , Vagina/diagnóstico por imagen , Vagina/cirugíaRESUMEN
BACKGROUND: Vaginal agenesis is a rare condition worldwide. Most reported cases were accompanied by the absence of uterus or uterine hypoplasia; for patients with functional endometrium, hysterectomy was most likely to be conducted to lower postoperative complications. OBJECTIVE: Based on our successful experience in vaginoplasty with autologous buccal mucosal, the purpose of this article is to discuss the surgical strategies in the reconstruction of neovaginal for vaginal agenesis patients with functional uterus and cervical hypoplasia. METHODS: The uterus was preserved in our procedure, and the cervicoplasty was performed to connect the uterine cavity with the neovagina. After the vaginal cavity was formed, the cervix was confirmed and fixed. With the assistance of laparoscope, the direction and angle of the cervix and the uterine body were observed and confirmed. An incision was made in cervix to connect the uterine cavity, and a Foley's catheter was inserted. The newly formed opening of cervix and neovagina was covered by autologous buccal mucosal. RESULTS: The connection between neovagina and cervix uteri was successfully conducted in patient with functional uterus. Unimpeded and regular menstrual was achieved, and the cyclic abdominal pain was disappeared. No complications were observed. CONCLUSION: For patients without functional uterus, vaginoplasty with autologous buccal mucosal can be conducted. However, fertility-preserving surgery should be the primary choice in patients with functional endometrium. It can be concluded from our experience that the utero-vaginal connection with the assistance of laparoscope and the use of autologous buccal mucosa is a promising way to achieve ideal outcomes.
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Procedimientos de Cirugía Plástica , Vagina , Cuello del Útero/anomalías , Cuello del Útero/cirugía , Anomalías Congénitas , Femenino , Procedimientos Quirúrgicos Ginecológicos , Humanos , Procedimientos de Cirugía Plástica/métodos , Útero/anomalías , Útero/cirugía , Vagina/anomalías , Vagina/cirugíaRESUMEN
INTRODUCTION: This study aimed to investigate amniotic fluid (AF) proteins that were differentially expressed between patients with cervical insufficiency (CI) and asymptomatic short cervix (SCX, ≤ 25 mm), and whether these proteins could be predictive of spontaneous preterm birth (SPTB) in these patients. METHOD: This was a retrospective cohort study of 129 singleton pregnant women with CI (n = 80) or SCX (n = 49) at 17 to 26 weeks who underwent amniocentesis. An antibody microarray was used to perform comparative proteomic profiling of AF from matched CI (n = 20) and SCX (n = 20) pregnancies. In the total cohort, an ELISA validation study was performed for 15 candidate proteins of interest. Subgroup analyses of patients with CI and SCX were conducted to evaluate the association between the 15 proteins and SPTB at < 32 weeks of gestation. RESULTS: Eighty-six proteins showed intergroup differences. ELISA validation confirmed significantly higher levels of AF EN-RAGE, IL-8, lipocalin-2, MMP-9, S100A8/A9, thrombospondin-2, and TNFR2 in patients with CI than in those with SCX. Multivariable analysis showed that increased AF levels of EN-RAGE, S100A8/A9, and uPA were independently associated with SPTB at < 32 weeks in patients with CI; whereas in patients with SCX, high AF levels of APRIL, EN-RAGE, LBP, and TNFR2 were independently associated with SPTB at < 32 weeks. CONCLUSIONS: Multiple AF proteins show altered expression in patients with CI compared with SCX controls. Moreover, several novel mediators involved in inflammation were identified as potential biomarkers for predicting SPTB after the diagnosis of CI and SCX. These results provide new insights into target-specific molecules for targeted therapies to prevent SPTB in patients with CI/SCX.
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Líquido Amniótico/inmunología , Anticuerpos/análisis , Nacimiento Prematuro/inmunología , Anomalías Urogenitales/inmunología , Incompetencia del Cuello del Útero/inmunología , Adulto , Líquido Amniótico/química , Líquido Amniótico/metabolismo , Anticuerpos/metabolismo , Enfermedades Asintomáticas , Estudios de Casos y Controles , Cerclaje Cervical/estadística & datos numéricos , Medición de Longitud Cervical , Cuello del Útero/anomalías , Cuello del Útero/patología , Cuello del Útero/cirugía , Estudios de Cohortes , Femenino , Humanos , Recién Nacido , Análisis por Micromatrices/métodos , Embarazo , Mantenimiento del Embarazo/fisiología , Resultado del Embarazo/epidemiología , Nacimiento Prematuro/epidemiología , Nacimiento Prematuro/etiología , Proteoma/análisis , Proteoma/metabolismo , Proteómica/métodos , República de Corea/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Anomalías Urogenitales/complicaciones , Anomalías Urogenitales/epidemiología , Anomalías Urogenitales/cirugía , Incompetencia del Cuello del Útero/epidemiología , Incompetencia del Cuello del Útero/etiología , Incompetencia del Cuello del Útero/cirugíaRESUMEN
BACKGROUND: Congenital external cervical os stenosis is a form of Mullerian duct abnormality which is rare in virginal adolescents. CASE: Pre-operatively, two non-sexually active adolescents of 12 and 14 years of age, with history of light menses and severe lower abdominal pain for 2 and 4 months respectively, were diagnosed with an obstructed, oblique vaginal septum syndrome. However, at operative vaginoscopy, a single cervix with a duplicated cervical os and unilateral cervical stenosis was discovered, confirming the diagnosis of a complete uterine septum involving the cervix and unilateral cervical stenosis. They were treated by expanding the affected external cervical os while leaving the hymen intact. A year following the treatment, follow up results found no recurrence of symptoms. SUMMARY AND CONCLUSION: Operative vaginoscopy using a hysteroscope is crucial and recommended for the diagnosis and treatment of congenital external cervical os stenosis in virginal adolescents.
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Cuello del Útero , Enfermedades del Cuello del Útero , Adolescente , Cuello del Útero/anomalías , Constricción Patológica , Femenino , Humanos , Lactante , Útero/anomalías , Vagina/anomalías , Vagina/cirugíaRESUMEN
Congenital anomalies of the female reproductive tract that present with primary amenorrhea involve Müllerian aplasia, also known as Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS), and cervical and vaginal anomalies that completely obstruct the reproductive tract. Karyotype abnormalities do not exclude the diagnosis of MRKHS. Familial cases of Müllerian anomalies and associated malformations of the urinary and skeletal systems strongly suggest a complex genetic etiology, but so far, the molecular mechanism in the vast majority of cases remains unknown. Primary amenorrhea may also be the first presentation of complete androgen insensitivity syndrome, steroid 5α-reductase type 2 deficiency, 17ß-hydroxysteroid dehydrogenase type 3 deficiency, and Leydig cells hypoplasia type 1; therefore, these disorders should be considered in the differential diagnosis of the congenital absence of the uterus and vagina. The molecular diagnosis in the majority of these cases can be established.
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Trastornos del Desarrollo Sexual 46, XX/patología , Amenorrea/genética , Amenorrea/patología , Cuello del Útero/anomalías , Anomalías Congénitas/patología , Conductos Paramesonéfricos/anomalías , Vagina/anomalías , 17-Hidroxiesteroide Deshidrogenasas/deficiencia , 17-Hidroxiesteroide Deshidrogenasas/genética , Síndrome de Resistencia Androgénica/genética , Síndrome de Resistencia Androgénica/patología , Cuello del Útero/embriología , Colestenona 5 alfa-Reductasa/deficiencia , Colestenona 5 alfa-Reductasa/genética , Anomalías Congénitas/diagnóstico , Trastorno del Desarrollo Sexual 46,XY/genética , Trastorno del Desarrollo Sexual 46,XY/patología , Femenino , Humanos , Masculino , Conductos Paramesonéfricos/patología , Testículo/anomalías , Testículo/patología , Vagina/embriologíaRESUMEN
There are many proposed classification systems for müllerian anomalies. The American Fertility Society (AFS) Classification from 1988 has been the most recognized and utilized. The advantages of this iconic classification include its simplicity, recognizability, and correlation with clinical pregnancy outcomes. However, the AFS classification has been criticized for its focus primarily on uterine anomalies, with exclusion of those of the vagina and cervix, its lack of clear diagnostic criteria, and its inability to classify complex aberrations. Despite this classification and others, the wide range of müllerian anomalies is still largely unknown and confusing to many providers. Consequently, müllerian anomalies may go undiagnosed for extended periods, receive inappropriate or inadequate surgical interventions, and result in persistent issues such as pain or loss of reproductive function. The American Society for Reproductive Medicine Task Force on Müllerian Anomalies Classification was formed and charged with designing a new classification. The Task Force set goals for a new classification and chose to base it on the iconic AFS classification from 1988 because of its simplicity and recognizability, while expanding and updating it to include all categories of anomalies. In addition, this was recognized as an opportunity to raise awareness of this area of medicine, educate providers and learners, and promote patient advocacy. Presented here is the new American Society for Reproductive Medicine Müllerian Anomalies Classification 2021.
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Técnicas de Apoyo para la Decisión , Imagen por Resonancia Magnética , Conductos Paramesonéfricos/diagnóstico por imagen , Terminología como Asunto , Ultrasonografía , Anomalías Urogenitales/diagnóstico por imagen , Útero/anomalías , Vagina/diagnóstico por imagen , Cuello del Útero/anomalías , Cuello del Útero/diagnóstico por imagen , Femenino , Humanos , Masculino , Conductos Paramesonéfricos/anomalías , Valor Predictivo de las Pruebas , Anomalías Urogenitales/clasificación , Útero/diagnóstico por imagen , Vagina/anomalíasRESUMEN
Diagnostic evaluation for infertility in women should be conducted in a systematic, expeditious, and cost-effective manner to identify all the relevant factors with an initial emphasis on the least invasive methods for detecting the most common causes of infertility. The purpose of this committee opinion is to provide a critical review of the current methods and procedures for the evaluation of in fertile women, and it replaces the document of the same name, last published in 2015 (Fertil Steril 2015;103:e44-50). This guidance is intended for any provider evaluating women for infertility.
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Fertilidad , Infertilidad Femenina/diagnóstico , Ovario/fisiopatología , Cuello del Útero/anomalías , Cuello del Útero/fisiopatología , Trompas Uterinas/fisiopatología , Femenino , Humanos , Infertilidad Femenina/etiología , Infertilidad Femenina/fisiopatología , Infertilidad Femenina/terapia , Reserva Ovárica , Ovulación , Valor Predictivo de las Pruebas , Embarazo , Índice de Embarazo , Técnicas Reproductivas Asistidas , Factores de Riesgo , Resultado del TratamientoRESUMEN
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.
Asunto(s)
Trastornos del Desarrollo Sexual 46, XX/cirugía , Cuello del Útero/cirugía , Anomalías Congénitas/cirugía , Procedimientos Quirúrgicos Ginecológicos , Conductos Paramesonéfricos/anomalías , Estructuras Creadas Quirúrgicamente , Vagina/cirugía , Trastornos del Desarrollo Sexual 46, XX/diagnóstico por imagen , Adulto , Cuello del Útero/anomalías , Anomalías Congénitas/diagnóstico por imagen , Femenino , Humanos , Conductos Paramesonéfricos/diagnóstico por imagen , Conductos Paramesonéfricos/cirugía , Técnicas de Sutura , Resultado del Tratamiento , Vagina/anomalíasRESUMEN
We describe a successful surgical technique of abdominal trachelectomy and re-vaginoplasty for cervico-vaginal stenosis following unsuccessful uterovaginal anastomosis and vaginoplasty in a patient with congenital cervical and vaginal aplasia. After the surgical procedure, cervico-vaginal stenosis was resolved and periodic menstruation without dysmenorrhoea resumed. While long-term follow-up is essential to ensure successful pregnancy and delivery, we conclude that this novel surgical procedure is a promising alternative for improvement of the quality of life and normal sexual function, and for preservation of fertility in patients with cervical and vaginal aplasia.