Laparoscopic Uterovaginal Anastomosis for Cervical Agenesis: A Case Report

Abstract

Study ObjectiveIsolated cervical agenesis occurs in 1 in 80 000 to 100 000 births. According to the American Fertility Society, cervical agenesis should be classified as a type Ib müllerian anomaly. According to ESHRE/ESGE classification, it is classified in class C4 category. Here we demonstrate the possibility of an innovative surgery for the management of cervical agenesis. DesignStepwise description of laparoscopic uterovaginal anastomosis (Canadian Task Force classification II-3). SettingVideo. PatientA 13-year-old girl. InterventionLaparoscopic uterovaginal anastomosis was performed. Informed consent was taken from the patient for use of video and images. Institutional review board has ruled that approval was not required for this study. Measurements and Main ResultsThis video demonstrates the management of a case of a 13-year-old girl with primary amenorrhea and cyclical lower abdominal pain for 5 months. After complete examination and investigation, a diagnosis of isolated cervical agenesis with hematomata and blind-ending vagina was made. An innovative technique was used to perform laparoscopic uterovaginal anastomosis. Later, a hysteroscopy was done that revealed patency of anastomoses. As a result, the patient is experiencing spontaneous regular menstruation for 48 months. The main steps of the procedure were as follows:1.Placement of uterine suspension sutures for manipulation and stabilization of the uterus.2.Infiltration of 10% vasopressin solution in the uterine fundus.3.Anteroposterior incision over the uterine fundus until the uterine cavity was reached and hematomata drained.4.Urinary bladder dissection to expose the vault of blind-ending vagina.5.An instrument was passed through the fundus to identify the lowermost pole of the uterine cavity and transverse incision made to open the uterine cavity.6.Transverse incision over the vaginal vault.7.Placement of a silastic Foley catheter as a stent between the vagina and uterine cavity.8.Uterovaginal anastomosis over the Foley catheter by placement of series of 2-0 Prolene (Ethicon, Somerville, NJ) sutures.9.Closure of uterine fundus with number 1 Vicryl (Ethicon).10.Distension of Foley bulb in uterine cavity with 3 mL normal saline.A follow-up hysteroscopy was performed at 9 weeks after surgery. It showed patent anastomosis and normal uterine cavity. After 48 months, a repeat hysteroscopy was done and a partial fibrotic septum noted. It was resected using electric energy. ConclusionUterovaginal anastomosis for isolated cervical agenesis is possible by a minimally invasive approach. It can be offered as a first-line management for such cases over hysterectomy and cervical canalization, which have high complication rates. The surgery should only be performed by a specialized team with required expertise in minimally invasive surgery.