Complete Longitudinal Vaginal Septum Resection and Hysteroscopic Metroplasty

Abstract

<h3>Study Objective</h3> To provide a brief overview of the negative fertility and pregnancy implications of a uterine septum, as well as to demonstrate the surgical management of a complete uterine and vaginal septum. <h3>Design</h3> Surgical video. Women with septate uterus have an increased relative risk of first trimester spontaneous abortion, second trimester spontaneous abortion, pre-term delivery, fetal growth restriction, malpresentation at delivery, and placental abruption. <h3>Setting</h3> Academic tertiary care hospital. <h3>Patients or Participants</h3> 31-year-old nulligravida who presents for consultation for a septate uterus. Pelvic MRI showed a subtle concavity of the external fundal uterine contour, with a complete fibromuscular septum which extended through the cervix. <h3>Interventions</h3> A hysteroscopic metroplasty was planned. An exam under anesthesia showed a previously unidentified complete longitudinal vaginal septum, which extended and communicated with a complete cervical/uterine septum. Kelly clamps were used to demarcate the anterior and posterior attachments of the vaginal septum and a dilute solution of vasopressin along with bupivacaine/epinephrine was injected. The Bovie cautery was used to excise the intervening septum progressively up to the cervix. Diagnostic hysteroscopy showed normal hemi-cavities with fluffy endometrium. The 24.5 French bipolar resectoscope with a roller barrel was used to divide the cervical and uterine septum. Care was taken to stay midline, and once the tubal ostia could be easily seen bilaterally, a slight convexity to the fundus was maintained ensuring integrity of the fundal myometrium. An intrauterine balloon stent was left in place for one week. <h3>Measurements and Main Results</h3> Office hysteroscopy after natural menses showed a normal vagina, cervix, and endometrial cavity. <h3>Conclusion</h3> MRI is the imaging of choice for identifying Müllerian anomalies and for surgical planning; however, a vaginal septum could be missed, reaffirming the importance of a careful examination under anesthesia. Hysteroscopic metroplasty is a safe and relatively simple procedure in those experienced with operative hysteroscopy and results in an improvement in fertility and pregnancy outcomes.