Uterine Remnants Research Articles

Symptomatic Uterine Rudiments in Adolescents and Adults with Mayer–Rokitansky–Küster–Hauser Syndrome (MRKHS): Management and Outcomes

Background: Women with an aplastic uterus (ESHRE/ESGE classification) or Müllerian agenesis (ASRM MAC 2021) might present with functional uterine remnants. Our study aimed to report the clinical course of symptomatic uterine rudiments in adolescents and adults with Mayer–Rokitansky–Küster–Hauser syndrome (MRKHS). Methods: This study involved 20 patients with MRKHS who, between 2012 and 2023, underwent surgery for symptomatic uterine horns at the mean age of 25.2 years in the Division of Gynaecology, Gynaecological and Obstetric Clinical Hospital, Poznan University of Medical Sciences, Poland. The records of the patients were retrospectively analysed. Results: The volume of the uterine horns ranged from 0.8 to 58.3 cm3, and the volume of the endometrial cavity within the horns ranged from 0.03 to 12 cm3, with no significant difference between adolescents and adults (p = 0.36). In five patients (25%), MRKHS was identified during the diagnosis of recurrent pelvic pain at the age of 12.6–14.8 years. In 19 patients, uterine rudiments were removed: unilaterally in 3 patients (16%), bilaterally in 16 patients (84%), and laparoscopically in 89% of cases. In one patient, the horn was preserved (horno-neovaginal anastomosis). Histopathology confirmed the presence of the endometrium in uterine rudiments ipsilateral to the pain location in 75% of cases. Four patients (20%) were diagnosed with endometriosis. Conclusions: Recurrent pelvic pain in patients with MRKHS should prompt the diagnosis of functional uterine rudiments. The resection of symptomatic uterine horns can result in the complete resolution of pain. Patients with endometriosis are at risk of pain recurrence. In some patients strongly desirous of menstruation, horno-neovaginal anastomosis can be cautiously attempted.

A Challenging Diagnosis - Large Leiomyomas on Rudimentary Uterus in Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome

A 40-year-old woman diagnosed with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome at 16 years of age presented with a large abdominal mass protruding to the right subcostal margin, equivalent to 30 weeks gestation. She didn’t have comorbidities of hypertension or diabetes. The vitals were normal with BMI 30. She was asymptomatic except for occasional vague abdominal discomfort. Further imaging studies were conducted to assess the extent and nature of the findings. Pelvic and transvaginal ultrasound demonstrated the presence of multiple large fibroids extending beyond the level of the umbilicus. This was corroborated by pelvic MRI, which further confirmed the massively enlarged multi-fibroid uterus. Additionally, intravenous contrast-enhanced imaging revealed large bilateral ovarian collaterals and prominent blood vessels extending to the broad ligament. Triple-phase CT angiogram of the abdomen/pelvis with pre-contrast revealed an 8mm aneurysm on the anterior aspect of the abdominal aorta and unusual vascular anatomy, raising the possibility of an atypical or neoplastic process in the right iliac fossa. In view of these findings, an opinion by an Oncologist was sought, who suspected the possible presence of an abnormal nidus of vessels and a fluid attenuation area in the right iliac fossa. Additionally, the Risk of Ovarian Malignancy Algorithm (ROMA) test was performed, revealing a slightly elevated value. To reach the final diagnosis, the decision for the exploratory laparotomy was undertaken. Intraoperative findings revealed the presence of a rudimentary uterus with normal ovaries (Figure 1 and Figure 2), as well as the presence of bilateral broad fibroids (Figure 3). The broad ligament areas around the uterus were occupied with large circumscribed masses, identified as fibroids. The right-side fibroid measuring 17 x 15cm (Figure 4) and the left-side fibroid measuring 10 x 10cm (Figure 5) were excised, respectively, while preserving the left ovary and rudimentary uterus. Peritoneal fluid samples were obtained to ascertain the nature of malignancy. No evidence of infiltration or adhesions was detected. Postoperatively, the patient experienced no complications. Histological examination of the masses growing from bilateral uterine remnants confirmed the presence of leiomyomas, with no glandular epithelium identified. Peritoneal fluid analysis revealed the absence of malignant cells.

Magnetic resonance imaging and clinical features of Mayer-Rokitansky-Küster-Hauser syndrome: A 10-year review from a dedicated specialist centre.

To correlate the clinical history with imaging findings of women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. Retrospective cohort study. A UK IOTA and ESGO-certified tertiary referral centre for disorders of reproductive development. All patients with a diagnosis of MRKH and who had undergone an MRI pelvis between 1 January 2011 and 31 April 2021 were included. MRI images were analysed by specialist gynaecological radiologists. Clinical data was extracted from an electronic patient record system. Statistical analysis was computed in R (version 4.1.2), R base stats package and ggstatsplot (v0.5.0). Clinical history and predefined imaging features. One hundred and thirty-four patients were included. Median age at MRI was 18 years (10-64 years). Half (48.2%) of women presenting had a history of pain, most often abdominal (84.6%) or vaginal (9.2%). Remnants were identified in 91.8% of women (n = 123). 4.5% of women had imaging features of endometriosis (n = 6). Women with a functional remnants were significantly more likely to experience pain (p < 0.001). Pain history was not strongly associated with ectopic ovarian position. Common gynaecological pathology such as endometriosis, ovarian cysts and fibroids were also identified. We identify that majority of women with MRKH will have uterine remnants with a connecting fibrous band, and an ectopic ovarian position 44.0% of cases. Abdominal pain was significantly associated with functional remnants on MRI. Further work is required to identify how other gynaecological pathology impacts women with MRKH.

Endometriosis and adenomyosis in a Mullerian agenesis patient: A delayed presentation

Mullerian duct anomalies are developmental anomalies resulting from failure in organogenesis, fusion, or the reabsorption of the paired Mullerian ducts. Endometriosis and Mullerian anomalies have a high coincidence rate. Obstructive uterine malformations with functioning endometrium have higher chances of co-incident endometriosis. Continuous bleeding into functional uterine remnants can lead to the formation of hematometra, endometriosis, and adenomyosis. We report a case of primary amenorrhea who reported 18 years after vaginoplasty with pain abdomen due to the presence of endometriosis in bilateral ovaries and adenomyosis in the rudimentary uterine horn.

75. Leiomyoma of a uterine remnant: Expand the differential for complex para-ovarian mass in patients with Mullerian agenesis

75. Leiomyoma of a uterine remnant: Expand the differential for complex para-ovarian mass in patients with Mullerian agenesis

Use of Advanced Preoperative Imaging in Classification of a Uterine Remnant

Use of Advanced Preoperative Imaging in Classification of a Uterine Remnant

Unification and orificing of two functional noncommunicating uterine horns through the created neovagina using peritoneum

ObjectiveTo demonstrate the surgical approach for Müllerian agenesis with bilateral uterine remnants containing functional endometrium. DesignStepwise demonstration of the technique with narrated video footage SettingA Tertiary University Hospital, Reproductive Surgery Unit. PatientAn 18-year-old adolescent was admitted to a tertiary university hospital with complaints of primary amenorrhea and cyclic pelvic pain. Physical examination and MRI scans suggested a complex Müllerian abnormality. The patient had uterine remnants with bilateral functional endometrium and cervico-vaginal agenesis. InterventionAn operation was planned to reconstruct her anatomy by providing a neovagina and anastomosing the uterine remnants. GnRH analogs were prescribed to suppress her menstruation until the procedure. The operation was performed in the third month after the initial diagnosis. A laparoscopy was conducted, revealing approximately 5x6 cm bilateral uterine horns with healthy adnexa.As the first step, a neovagina was created using a modified peritoneal pull-down technique, a standard approach in our clinic. A vaginal incision was made, and a blind vaginal dissection was performed to reach the peritoneum vaginally. Subsequently, an acrylic vaginal mold was inserted. The vaginal orifice was laparoscopically incised using ultrasonic energy with guidance from the inserted vaginal acrylic mold. The orifice was gradually dilated with larger molds. The entire pelvic peritoneum was dissected circularly, and the distal part of the dissected peritoneum was pulled down using four 2.0 Vicryl sutures at 0, 90, 180, and 270 degrees from the opened vaginal orifice. The uterine cavities of both remnants were incised, and two separate Foley catheters were placed in both cavities. A mold with a hole was used to insert the catheters through the vagina. Both catheters were secured in the cavities with Prolene sutures pulled up from the anterior abdominal wall.The next step involved uterine anastomosis. The uterine remnants were unified through continuous suturing, resulting in the formation of a normally shaped uterus. In the final step, the created uterus and neovagina were anastomosed. The patient received instructions on how to perform mold exercises and follow-up care. Main Outcome MeasureDescription of a laparoscopic management of a rare mullerian abnormality. ResultsThe postoperative MRI scan at one month revealed healed unified uterine cavities and vagina. The patient experienced spontaneous menstruation in the second month after surgery and now maintains regular menses with an approximately 9-10 cm functional vagina. Within three months after surgery, the VAS (visual analog scale) scores for chronic pelvic pain and dysmenorrhea decreased from 9 to 2-3. ConclusionsMüllerian abnormalities are exceptionally rare, and their spectrum is broad, making it challenging to identify an exact surgical method to restore functional anatomy. Therefore, a customized surgical approach should be designed for each patient based on their unique condition.

Congenital Adrenal Hyperplasia with Concomitant Mullerian Agenesis: A Rare Occurrence in 46 Xx Disorders of Sexual Development

The most common cause of 46 XX DSD is due to congenital adrenal hyperplasia with varying degrees of virilization. Females with CAH do not produce an anti-mullerian hormone (AMH), therefore the internal genitalia, which are Mullerian derivatives, develop normally. We report a unique case of CAH with aplasia of the uterus and upper vagina. The clinical, laboratory, and imaging findings of the patient are presented with a review of the literature. We report an ongoing case of a 20-year-old patient with ambiguous genitalia and primary amenorrhea. On physical examination, we found that she had an underdeveloped breast and clitoral virilization with separate urethral and vaginal openings. We performed a G-banded chromosome analysis, with 46 XX results. Laboratory test showed her 17-hydroxyprogesterone level was immensely elevated, while her FSH, LH, and estradiol level was below normal. Ultrasound imaging revealed the absence of uterus and cervix. Nevertheless, we found a diminutive uterine remnant during diagnostic laparoscopy with normal ovaries and fallopian tubes. On vaginoscopy examination, we found her vagina to be 5 cm long with blind end. In the presence of primary amenorrhea in patients with CAH, it is important to investigate for possible associated mullerian anomalies.

FRI413 Hormonal Menstural Suppression For Menstrual Obstruction: A Retrospective Review Of Patients With Complex Obstructed Uterovaginal Anomalies Who Underwent Surgical Management In A Tertiary Referral Centre

Abstract Disclosure: H.I. Learner: None. S.M. Creighton: None. S.A. Clarke: None. Aims: To describe the use of hormonal menstrual suppression in patients undergoing surgery for complex utero-vaginal anomalies with menstrual obstruction. Background: Obstructed menstruation can present with painful primary amenorrhea or progressive dysmenorrhea due to unilateral obstructing duplication utero-vaginal anomalies. Menstrual suppression is essential to relieve pain during investigation and surgical planning. The off licence use of progestogens, hormonal contraception and GNRH analogues is common but there is little literature describing their best use in this context. Methods: This was a retrospective case series review of patients undergoing surgical management of complex menstrual obstruction in a tertiary referral centre between 2016-2022. Data collected on age, diagnosis, symptoms, duration of symptoms, surgery, the type of endometrial suppression used and associated side effects.Patients with partial obstruction were excluded. Results: Eighty-four patients were identified from the surgical database. The median age at time of surgery was 16 years (range 11-36). Unilateral obstruction was managed in 53/84 and complete obstruction in 31/84. Diagnoses included obstructed hemi-vagina (32/84), unicornuate uterus with functional uterine remnant (19/84), transverse vaginal septum (15/84), cervical/vaginal agenesis (9/84), and Mullerian agenesis with functional uterine remnant (5/84). Symptom duration information was available in 74/84 with a median of 10 months(0-252 months). Changes to endometrial suppression treatment were required in most patients, with 50/84 (40%) remaining on their original prescription. The average number of treatment regimes was 2 (0-7). Menstrual suppression at time of surgery was Norethisterone 35/84 (42%), Continuous combined oral contraceptive pill18/84 (21%), Medroxyprogesterone 11/84 (13%), GNRH 10/84 (12%), Desogestrel 6/84 (7%), and Depo-Provera 4/84 (5%). Tibolone was used as add-back in five patients on GNRHa for more than 6 months duration of use (4/5) or hypoestrogenic side-effects (1/5) . Conclusion Menstrual suppression for pain relief is an essential component in management for complex uterovaginal anomalies. Suppression should be started at initial presentation but there is limited guidance for clinicians as to what and how to prescribe. Our study has demonstrated that this can lead to chaotic prescribing, unnecessary pain and multiple treatment changes. Presentation: Friday, June 16, 2023

Long term sexual outcomes of Mayer Rokitansky Küster Hauser Syndrome patients after Uncu-modified Davydov procedure.

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome has an incidence of 1 in 4000. The absence of the vagina and uterus results in sexual dysfunction and infertility. The first-line treatment is vaginal dilatation. There exists a number of second-line surgical options including the Uncu-modified Davydov procedure. To determine the complication rate, anatomical outcomes, and long-term sexual outcomes of MRKH syndrome patients after Uncu-modified Davydov procedure. Patients with MRKH syndrome who underwent paramesonephric remnant-supported laparoscopic double-layer peritoneal pull-down vaginoplasty (aka Uncu-modified Davydov procedure) between January 2008 and December 2021. The procedure involves laparoscopic circular dissection of the pelvic peritoneum followed by pulling down, through the opened vaginal orifice, and suturing the vaginal cuff with the support of uterine remnants. The long-term complication rate, anatomical outcomes, and sexual function outcomes (as measured by Female Sexual Function Index (FSFI)) were ascertained. Main Outcome Measures: The long-term complication rate, anatomical outcomes and FSFI survey results. A total of 50 patients with MRKH syndrome underwent the Uncu-modified Davydov procedure between Jan 2008- Dec 2021. There were four perioperative complications: three bladder injuries (6%) and one rectal serosa injury (2%). Four long-term postoperative complications were identified: one vesicovaginal fistula (2%), one recto-vaginal fistula (2%), and two vaginal stenoses (4%). All patients were physically examined at least one year after surgery. The mean vaginal length was 8.4 + 1.9 cm. The mean FSFI score was 31.5 + 3.9 (minimum score of 24, maximum score of 36). Conclusion: The Uncu-modified Davydov procedure has been demonstrated to be a safe and effective treatment option with high female sexual function index scores for patients with MRKH syndrome. The long-term complication rate, anatomical and sexual outcomes of Uncu-modified laparoscopic peritoneal pull-down vaginoplasty were reported in this study. The results indicated that the surgical approach could be used in selective MRKH patients who failed first-line self-dilatation therapy.

Mayer–Rokitansky–Kuster–Hauser syndrome (MRKH) and Ovarian Cyst : A Rare Case

Background: In the most recent publications on Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, the uterine remnants and ovaries in patients may develop uterine remnant leiomyoma, adenomyosis, or ovarian tumor, and this can lead to problems in differential diagnosis. Here we summarize the diagnosis methods and available interventions for ovarian tumor in MRKH syndrome, with emphasis on the relevant clinical findings and illustrative relevant case. According to the clinical findings and illustrative relevant case, with the help of imaging techniques, ovarian tumors can be detected in the pelvis in patients with MRKH syndrome and evaluated in terms of size. Laparoscopy could further differentiate ovarian tumors into different pathological types. In addition, laparoscopic surgery not only is helpful for the diagnosis of MRKH combined ovarian tumor, but also has a good treatment role for excising ovarian tumor at the same time. Moreover, laparoscopic removals of ovarian tumor can be considered as a safe and reliable treatment for conservative management.Case report: 25-year-old nulliparous woman with female phenotype and normal secondary sex development presented with complaints of primary amenorrhea and difficulty in sexual intercourse. Physical examination revealed that there were no vaginal and uterus structure. A transvaginal ultrasound examination showed absent of uterine . normal right ovariesand cystic mass in left adnexa . Laparoscopy cystectomy and amniograft vaginoplasty  was performed in this patient. Histopatology result showed Cystadenoma srous ovarii with borderline serous ovarii.Conclusion: Rarely ovarian cyst was associated with MRKH . Although malformation are associated with MRKH syndrome. Association  beetween MRKH syndrome and ovarian cyst can be foundÂ

5. Minimally Invasive Techniques for Uterine Remnant Removal

5. Minimally Invasive Techniques for Uterine Remnant Removal

Urogenital fistula associated with complex dystocia and emergency ovariohysterectomy in a juvenile dog

AbstractA 1‐year‐old, female, spayed dog was referred for urinary incontinence, first noted after a complex dystocia and caesarean section with ovariohysterectomy. Transabdominal ultrasonography and computed tomography with intravenous contrast administration revealed a fluid‐filled tubular structure caudodorsal to the urinary bladder. Routine cystourethroscopy was unremarkable. A retrograde cystourethrogram revealed a 15 mm long connection between the urethra and a structure presumed to be a uterine body remnant. During exploratory laparotomy, the uterine remnant and urethra were separated, leaving oval defects approximately 15 mm long in both; these were then closed. A urinary catheter was left in place for 6 days. A urethrogram performed during catheter removal confirmed closure of the fistula, and the dog was subsequently continent. To the authors’ knowledge, this is the first description of a urogenital fistula suspected to be associated with dystocia and emergency ovariohysterectomy in a dog.

Laparoscopic Neovagina Creation by Using Modified Davydov Technique

A-21 year-old woman diagnosed with Meyer Rokitamsky Kuster Hauser syndrome has presented with a complaint of amenorrhea and failure to have vaginal penetration during coitus. On magnetic resonance imaging, bilateral rudimentary uterine remnants next to normal-appearing ovaries with absence of uterus have been detected. Laparoscopically, a 3 cm transverse incision was made pelvic peritoneum and vaginal apex to create a two-finger width opening to the blind vagina. Anterior and posterior visceral peritoneal edges have been grasped and sutured vaginally to the vaginal epithelial border. A continuous purse string stitch technique has been utilized to close the proximal part of the neovagina. The postoperative course of the patient was uneventful. The patient kept using a vaginal silicone dilatator every night for 3 months and she was allowed to have regular coital activity after then. The modified Davydov procedure is an efficient surgical technique with lower complication rates and vaginal stenosis rates.

Endometriosis in Patients with Mayer-Rokitansky-Küster-Hauser-Syndrome—Histological Evaluation of Uterus Remnants and Peritoneal Lesions and Comparison to Samples from Endometriosis Patients without Mullerian Anomaly

Congenital Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a Mullerian-duct anomaly that is characterized by agenesis of the uterus and upper part of the vagina. Uterus remnants of varying sizes can often be found. Although a functional uterus is missing, the existence of endometriosis in this patient group has been described in the literature; however, a histopathological comparison of the characteristics of the endometrium within the uterus remnants versus endometriotic peritoneal lesions in the same patient is lacking. Moreover, the characteristics of endometriotic tissue in patients with MRKH syndrome have not been correlated with those of patients with endometriosis without Mullerian anomaly. Patients who underwent laparoscopic neovagina creation with the removal of uterus remnants and possible resection of endometriotic lesions between 2010 and 2022 at the Department of Women's health of the University of Tuebingen were included in our study. Uterine remnants and endometriotic tissue were evaluated via histopathology and immunohistochemistry and were compared to endometriotic samples from patients without Mullerian anomaly. Endometriosis was detected in nine MRKH patients; in four patients, endometrial remnants could be sufficiently compared to endometriotic lesions. All samples exhibited increased expression of hormonal receptors. In two patients, Ki67 proliferation index was significantly increased in peritoneal endometriotic lesions compared with the endometrium of the remnants. In contrast, endometrium and endometriotic lesions of endometriosis patients did not exhibit any differences in the Ki67 proliferation index. Our results demonstrate distinctive immunohistochemical variability between uterine remnants and endometriotic lesions in patients with MRKH syndrome compared with patients with endometriosis, indicating a possible explanation model of the yet-unknown etiology of endometriosis. For confirmation, investigation of a broader patient collective is necessary.

Laparoscopic removal of bilateral uterine remnants for symptomatic unilateral leiomyomas in a patient with Müllerian agenesis

To our knowledge, we present the first video demonstration of the laparoscopic removal of bilateral uterine remnants for symptomatic unilateral leiomyomas in a patient with Müllerian agenesis. A video case report. An academic medical center. A 44-year-old woman, gravida 0, with a history of Müllerian agenesis with presumed single uterine remnant who presented with worsening lower abdominal fullness and discomfort in the setting of known leiomyomas. Magnetic resonance imaging of the pelvis revealed a single rudimentary uterine remnant with 3 dominant leiomyomas, with the largest measuring 5.8 × 5.3 × 5.2 cm. After extensive counseling, she opted for definitive surgical management. She provided written consent for video recording and publication of this surgical case. Laparoscopic removal of bilateral uterine remnants, bilateral salpingectomy, and cystoscopy. Laparoscopic removal of bilateral uterine remnants with multiple unilateral leiomyomas, leading to resolution of lower abdominal bulk symptoms. Diagnostic laparoscopy revealed a right 12-cm pelvic mass consisting of a uterine remnant with 3 dominant leiomyomas, left 2-cm rudimentary uterine remnant, bilateral atrophic fallopian tubes, bilateral normal ovaries, and absent cervix and upper vagina. Procedure was uncomplicated with an estimated blood loss of 25 mL. Patient was discharged on the same day of surgery after meeting required milestones. Pathologic examination of the specimens was consistent with intraoperative findings. Müllerian agenesis is a rare congenital anomaly of the female reproductive tract in which uterine remnants may be found. Leiomyoma formation in uterine remnants is rare but possible. Magnetic resonance imaging is the most sensitive imaging modality for uterine remnants but not always accurate. When leiomyomas become symptomatic, surgery is the only definitive management option with laparoscopy as the standard of care when possible. Minor changes to the minimally invasive approach may be necessary to accommodate for anatomical differences.

Clinical Features and Management of Endometriosis among Patients with MRKH and Functional Uterine Remnants

Objective: This study aimed to determine the clinical features of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome patients with functional uterine remnants and endometriosis in a large cohort of Chinese patients. Design: This was a retrospective study. Participants: This study had a cohort of 511 MRKH patients. A total of 34 MRKH patients with functional remnant were finally included. Setting: This study included a tertiary referring hospital in China. Methods: Patients with MRKH diagnosed and treated at Peking Union Medical College Hospital from January 2009 to January 2020 were recruited. A cohort of 511 MRKH patients were retrospectively screened, and a total of 34 MRKH patients with functional remnant were finally included. Relevant clinical data were reviewed retrospectively from medical charts. Results: Of 34 patients with MRKH and functional uterine remnants, 23 (68%) had endometriosis. These patients had a greater mean age at MRKH diagnosis than patients without endometriosis (15.9 ± 3.3 years vs. 13.2 ± 3.5 years; p = 0.03). Similarly, these patients experienced a longer time between age at onset of symptoms and age at operation than patients without endometriosis (45.5 ± 39.6 years vs. 19.8 ± 13.2 years; p = 0.04). In addition, the CA125 level was significantly higher in patients with endometriosis than in those without it (64.9 ± 85.9 U/mL vs. 25.5 ± 19.1 U/mL; p = 0.03). Limitations: The number of patients with MRKH analyzed in this study was low as we restricted inclusion to patients with at least 1 functional uterine remnant or endometriosis. Conclusions: It is reasonable to monitor the uterine remnant of patients with MRKH closely, regardless of age, to achieve early intervention. The level of CA125 might be helpful to differentiate active uterine remnants with endometriosis and schedule individualized treatments.

A case of neovagina surgical creation using the uterine cervix remnant in a patient with Mayer-Rokitansky-Küster-Hauser syndrome

To study the efficacy of a novel approach to vaginoplasty in a patient with vaginal aplasia and a preserved cervix. 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. 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. A single patient, mentioned previously. Surgical vaginoplasty using the preserved cervix. The details are explained in the Design section. Restoration of the normal vaginal anatomy and function. 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. 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.

Laparoscopic Hysterectomy with Cervicovaginal Agenesis

Video Objective We present a laparoscopic surgical approach for hysterectomy in Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome with cervicovaginal agenesis. Laparoscopic approaches for removal of uterine remnants have been published with only reports of laparotomy described for hysterectomy with cervicovaginal agenesis. Setting We discuss the diagnosis, management considerations and preoperative planning for definitive surgical treatment of a patient with MRKH with cervicovaginal agenesis presenting with hematometra and pain. Patient initially presenting with primary amenorrhea and pain, with previous medical treatment to achieve amenorrhea. Interventions Laparoscopic hysterectomy with bilateral ureterolysis and uterine artery ligation in a patient with cervicovaginal agenesis. Conclusion We show that laparoscopic hysterectomy is a viable and safe option in patients with cervicovaginal agenesis. The importance of preoperative imaging to rule out associated anomalies and assist in surgical planning is stressed. We highlight necessary alterations in surgical technique to overcome the lack of traction, identify potential anomalous vasculature and ultimately maintain hemostasis, clear delineation of surgical anatomy, and avoid injury. Tissue extraction through laparoscopic in bag morcellation is performed thus avoiding mini laparotomy altogether.

Uterine stump adenocarcinoma in a bitch with an ovarian remnant: A case report

A 3-year-old female spayed dog was presented with a history of sanguineous vaginal discharge of 2 month duration. The dog was spayed 1.5 years before presentation. Clinical examination revealed a large, solid, ovoid mass in the caudal abdomen, recognized by diagnostic imaging as an enlargement at the top of the uterine stump. Additionally, high serum progesterone concentration was measured, confirming the presence of functional ovarian tissue in dioestrus. With a suspicion for a related uterine stump pyometra or less likely, for other enlargements, a cοeliotomy was performed. A mass at the apex of the uterine body and a right side ovarian remnant were found. Both structures and the remaining uterine stump were excised. The uterine remnant mass was histologically diagnosed as uterine adenocarcinoma, herein detected for the first time at the uterine stump in the bitch. Unsuccessful, incomplete ovariohysterectomy may permit even neoplastic transformation of uterine stump tissues.