Laparoscopic management of cervical agenesis

OBJECTIVE

To assess the possibility of laparoscopic management of cervical agenesis.

DESIGN

Case report.

SETTING

Patient recruited from a tertiary referral hospital.

PATIENT(S)

Adult female with diagnosis of cervical agenesis.

INTERVENTION(S)

Laparoscopic uterovaginal anastomosis.

MAIN OUTCOME MEASURE(S)

The patency of the anastomosis site was assessed with hysteroscopy.

RESULT(S)

Patient was menstruating normally and had been sexually active at 6 months after the procedure.

CONCLUSION(S)

Laparoscopic treatment of these cases is feasible and should be considered as a first-line treatment option.

Septate uterus with cervical duplication and a longitudinal vaginal septum: a müllerian anomaly without a classification

OBJECTIVE

To report a rare uterine anomaly of a septate uterus, double cervix, and double vagina.

DESIGN

Case report.

SETTING

A university-based reproductive endocrinology center.

PATIENT(S)

A 20-year-old nulligravida with primary infertility.

INTERVENTION(S)

Clinical examination and surgical resection of a vaginal septum with hysteroscopic examination of both hemicavities.

MAIN OUTCOME MEASURE(S)

Description and treatment for a rare uterine anomaly and a subsequent literature search.

RESULT(S)

Successful resection of vaginal septum and subsequent spontaneous pregnancy.

CONCLUSION(S)

This rare anomaly is not explained by classic embryologic teaching and is not described by the classification system currently used to describe müllerian anomalies.

Giant supratrigonal vesicocervicovaginal fistula--a case report

Vesicovaginal fistula (VVF) is prevalent in the developing world, with recent estimates suggesting that 2 million women live with fistula, mainly in sub-Saharan Africa and South Asia. VVF is associated with urogenital infections and ammonia dermatitis, and the psychosocial ramifications may be devastating, as women may be socially isolated from their families and community. VVF also remains a challenging condition for the gynecologic surgeon. We present a case of a giant supratrigonal VVF repaired using an abdominal (suprapubic) transperitoneal transvesical approach.

Transvaginal ultrasonography of the cervix to predict preterm birth in women with uterine anomalies

OBJECTIVE

Women with uterine anomalies have higher rates of preterm birth, but the reason for this has not been elucidated. Transvaginal ultrasound examination has been shown to be an accurate test for the prediction of preterm birth but has not been studied specifically in this population.

METHODS

Pregnant women with uterine anomalies were followed prospectively with transvaginal ultrasound examination of the cervix, performed between 14 and 23 6/7 weeks of gestation. A short cervical length was defined as less than 25 mm of cervical length. The primary outcome was spontaneous preterm birth, defined as birth at less than 35 weeks.

RESULTS

Of the 64 pregnancies available for analysis, there were 28 with a bicornuate uterus, 13 with a septate uterus, 11 with a uterine didelphys, and 12 with a unicornuate uterus. The overall incidence of spontaneous preterm birth at less than 35 weeks was 11%. Of the 10 (16%) women with a short cervical length, 5 (50%) had spontaneous preterm birth. Of the 54 women without a short cervical length, only 2 (4%) had a spontaneous preterm birth. The sensitivity, specificity, and positive and negative predictive values of a short cervical length for spontaneous preterm birth were 71%, 91%, 50%, and 96%, respectively (relative risk 13.5, 95% confidence interval 3.49-54.74). Of the 7 women with both short cervical length and preterm birth, all uterine subtypes were represented except septate uterus.

CONCLUSION

A short cervical length on transvaginal ultrasonography in women with uterine anomalies has a 13-fold risk for preterm birth. Unicornuate uterus had the highest rate of cervical shortening and preterm delivery.

LEVEL OF EVIDENCE

II-2.

The VCUAM (Vagina Cervix Uterus Adnex–associated Malformation) Classification: a new classification for genital malformations

OBJECTIVE

With an incidence of up to 5% in the general population, genital malformations are a frequent clinical occurrence. However, using the existing published classifications of malformations, difficulties arise in classifying genital malformations appropriately. The aim of the present study was to produce a simple, systematic, and reproducible classification system.

DESIGN

A systematic arrangement of genital and associated malformaltions, using a structure similar to that in the TNM classification of oncological tumors, was developed and validated.

SETTING

Patients with genital malformations in a university hospital.

PATIENT(S)

Ninty-nine premenopausal patients with genital malformations.

INTERVENTION(S)

Patients were diagnosed for genital malformation using laparoscopy or magnetic resonance imaging.

MAIN OUTCOME MEASURE(S)

A new classification (VCUAM) is presented to evaluate patients with different genital malformations.

RESULT(S)

The external and internal female genital organs were divided into the following subgroups in accordance with the anatomy: vagina (V), cervix (C), uterus (U), and adnexa (A). Associated malformations were assigned to a subgroup (M) relative to each specific organ. The classification was validated in a group of 99 patients with genital malformations.

CONCLUSION(S)

The VCUAM classification for the first time makes it possible to reflect even complex malformations in a precise and individual fashion, taking associated malformations into account. The classification makes it easier to provide appropriate clinical care for the affected patients.

Abdominal surgical approach to a case of complete cervical and partial vaginal agenesis

OBJECTIVE

To construct a uterovaginal canal in a patient with a complete cervical agenesis and partial vaginal agenesis.

DESIGN

Case report.

SETTING

Zeynep Kamil Women's and Children Hospital.

PATIENT(S)

A 15-year-old woman presented with lower abdominal pain. On examination, partial vaginal agenesis with a 4-cm vagina was noted. A pelvic ultrasonography revealed hematometra and the absence of a cervix.

INTERVENTION(S)

Surgical therapy included creation of an ostium by making 1.5-cm midline vertical hysterotomy incision, trimming away the fibrous tissue at the distal portion of uterus, and attaching the proximal end of the vagina to the uterus by the abdominal route. A stent was left in place for 2 weeks.

MAIN OUTCOME MEASURE(S)

Pelvic ultrasonography and clinical follow-up evaluation.

RESULT(S)

Regular menstrual periods were observed for 6 months beginning at the first month. The follow-up pelvic ultrasonography was normal.

CONCLUSION(S)

Cervicoplasty attaching the mucosal lining of the endometrium to that of the vagina permits the creation of a patent cervical canal with short stenting time.

Successful treatment of cervical aplasia using a peritoneal graft

OBJECTIVE

To evaluate the efficacy of a peritoneal graft for the treatment of cervical aplasia.

METHOD

Four patients with cervical aplasia who had a functioning endometrium and hematometra were recruited for this clinical trial. Through an abdominoperineal approach a plastic stent was inserted between the endometrial cavity and the upper part of the vagina; then, a graft of peritoneum was applied over the stent. In the absence of a vagina, grafts of skin or amniotic membrane were also used. The plastic stent was removed after 1 month in 2 patients and after 1 week in the 2 other patients.

RESULT

After more than 1 year of observation the 4 patients had regular menstrual cycles with normal menstruation. Sonographic examinations also showed empty uterine cavities.

CONCLUSION

Traditional gynecology textbooks recommend hysterectomy in cases of cervical aplasia. This report presents a new technique with 2 variations using a peritoneal graft. Although both variations were successful in the treatment of cervical aplasia in 4 women, more trials are needed to determine which one should be developed.

Complex malformations of the female genital tract. New types and revision of classification

BACKGROUND

Complex malformations of the female genital tract are often incorrectly identified, treated and reported, probably due to not considering the malformation as a cause of the clinical symptoms and neither the embryological origin of the different elements of the genitourinary tract.

METHODS

Complex malformations are studied and classified, and new types are presented. The new types of complex malformations presented are: (i) Cases of unilateral vaginal or cervico-vaginal atresia with renal agenesis and uterine duplication, with or without communication between hemiuteri; (ii) the unilateral Rokitansky syndrome; and (iii) the combination in the same patient of unilateral Rokitansky syndrome (Müllerian defect) on one side and blind vagina and ipsilateral renal agenesis syndrome (Wolffian defect) on the other side.

RESULTS

A revised version of the clinical and embryological classification of genital malformations is presented and an associated diagram points out the origin of these malformations.

CONCLUSIONS

These genital malformative anomalies reaffirm our hypothesis about the embryology of the human vagina as deriving from the Wolffian ducts and the Müllerian tubercle; and they show that gynecologists should be aware of the related symptoms and the embryology of the female genital tract in order to achieve a better comprehension of the malformations for their right correction or therapeutic approach.

Septate uterus with a double cervix and longitudinal vaginal septum

OBJECTIVE

To report the clinical features of 9 cases and review the previously reported 8 cases of an uncommon müllerian anomaly, characterized by the presence of a complete uterine septum with cervical duplication and represent a a longitudinal vaginal septum.

STUDY DESIGN

Retrospective clinical study.

RESULTS

Nine patients aged 21-32 presented to our clinic with complaints of dyspareunia, dysmenorrhea, and primary or secondary infertility. All 9 patients displayed a single uterus with smooth fundal contour, double cervix and longitudinal vaginal septum. Some additional abnormal findings were associated with these anomalies in some patients: polycystic ovaries in 3 cases and different degrees of endometriosis in 2 cases. Most of the patients had normal tubal patency.

CONCLUSION

According to a MEDLINE search, only 8 cases of septate uterus with cervical duplication and a longitudinal vaginal septum have been reported to date. We report 9 more cases, which suggest that this atypical septate uterus type is probably more frequent than reported. These cases support the bidirectional müllerian theory and may imply the presence of another type of mullerian anomaly.

Double cervix and vagina with a normal uterus and blind cervical pouch: A rare müllerian anomaly

OBJECTIVE

To report a rare müllerian anomaly with a blind cervical pouch.

DESIGN

Case report.

SETTING

Private practice and community hospital.

PATIENT(S)

A 27-year-old nulliparous patient referred for evaluation of suspected müllerian anomaly.

INTERVENTION(S)

Clinical and outpatient surgical evaluation of the anomaly.

MAIN OUTCOME MEASURE(S)

Assessment of the anomaly according to standard müllerian classification system and subsequent literature search.

RESULT(S)

A rare müllerian anomaly was found that did not fit within the standard classification system, which included a double cervix and vagina with a normal uterus and blind cervical pouch. This was found to have been described only once before after extensive review of the literature.

CONCLUSION(S)

The described anomaly is extremely rare, with no prior cases reported in the United States. The described anomalies in this case report are inconsistent with the generally accepted understanding of müllerian development and do not fit into the current classification system.

Vaginal and cervical atresia in a cynomolgus macaque

A female cynomolgus monkey presented clinically with a caudal abdominal mass noted on a prestudy physical examination. No other clinical abnormalities were noted. An ultrasound examination revealed a mass approximately 2 cm in diameter, which contained fluid with a granular "free-floating" appearance. Within a month the mass enlarged and was visible from external examination. Exploratory laparotomy revealed a mass encompassing the uterus, both ovaries, bladder, and rectum. The animal was euthanized under anesthesia, and the mass was removed, examined, and submitted for histopathology. A diagnosis of vaginal and cervical atresia was made. To the author's knowledge, this is the first description of vaginal and cervical atresia in a laboratory nonhuman primate.

Uterine cervical diverticulum resembling a degenerated leiomyoma

BACKGROUND

Uterine diverticulum is a very rare anomaly. Most previously reported cases were called "pregnancy-associated sacculations," and only 2 cases were considered true uterine diverticula.

CASE

A 41-year-old woman presented with fever and lower abdominal pain. An extrauterine mass was detected, and a hysterectomy was performed. Pathological examination revealed a cystic uterine diverticulum lined with cervical glands and myometrium arising from the cervix. The final diagnosis was an infected uterine cervical diverticulum.

CONCLUSION

Cervical diverticulum is a rare lesion that should be added to the differential diagnosis of a woman presenting with a pelvic mass.

The diagnosis and reproductive outcome after surgical treatment of the complete septate uterus, duplicated cervix and vaginal septum

OBJECTIVE

This study was undertaken to evaluate the diagnostic management and the reproductive outcome after surgical repair of a rare reproductive malformation.

STUDY DESIGN

Sixteen women with a complete septate uterus, double cervix, and a longitudinal vaginal septum were referred for evaluation. Presenting complaints were chiefly pregnancy loss in parous women (n=9) and dyspareunia in nulligravid women (n=7). The combination of hysterosalpingography, ultrasonography, and/or magnetic resonance imaging was used to correctly identify the anomaly in 15 of the 16 cases. Both hysteroscopic (n=11) and transabdominal (n=5) surgical techniques were used to repair the uterine septum.

RESULTS

In no case was the correct diagnosis made before referral; the uterus didelphys was the most common misdiagnosis. The preoperative pregnancy loss was 81%. Postoperatively, 12 women conceived for a total of 17 pregnancies; there were 14 term live births or ongoing pregnancies in the third trimester (82%), with a first trimester spontaneous abortion rate of 18%. In 9 women who conceived after hysteroscopic surgery, term live births occurred in 9 of 12 (75%) conceptions. A modified Tompkins metroplasty was performed in 5 women with subsequent term live births or ongoing third trimester pregnancies in 5 of 5 (100%) patients.

CONCLUSION

The identification of a duplicated cervix and a vaginal septum is consistent with several uterine malformations, which leads to frequent misdiagnosis and errors in management. Significant pregnancy wastage, obstetric complications, and dyspareunia are common, and surgical treatment is therefore advisable. Making the best choice between hysteroscopic or transabdominal metroplasty depends on the anatomic features of the cervix and the uterine cavity, but optimal patient management requires familiarity with both techniques.

Successful end-to-end cervico-cervical anastomosis in a patient with congenital cervical fragmentation: case report

Cervical agenesis or dysgenesis (fragmentation, fibrous cord and obstruction) is an extremely rare congenital anomaly. Conservative surgical approach to these patients involves uterovaginal anastomosis, cervical canalization, and cervical reconstruction. In failed conservative surgery, total hysterectomy is the treatment of choice. We report what we believe to be the first successful end-to-end cervico-cervical anastomosis of an unusual case of congenital cervical fragmentation. A 15 year old Caucasian female presented complaining of primary amenorrhoea and cyclic, monthly abdominal pain. At laparotomy, a symmetrical transverse disruption of the cervix in a central and distal part was found and an end-to-end cervico-cervical anastomosis of the two cervical fragments was performed with the use of a 16F Foley catheter as a stent into the endocervical canal. One month after surgery the patient had normal menses. We conclude that a thorough investigation of the patient with suspected cervical anomaly is necessary and conservative surgical treatment should be applied as a first-line treatment option. In the presence of functional and intact cervical segments, the reconstruction of the cervical canal with an end-to-end cervico-cervical anastomosis is feasible and effective.

Septate uterus with cervical duplication: a full-term delivery after resection of a vaginal septum

We report a full-term delivery after resection of a longitudinal vaginal septum in a patient with a septate uterus and cervical duplication.

Septate uterus with cervical duplication and longitudinal vaginal septum: a report of five new cases

OBJECTIVE

To describe a unique congenital müllerian anomaly.

DESIGN

Case report.

SETTING

A university-based reproductive endocrine center.

PATIENT(S)

Five reproductive-age, nulligravida patients who underwent clinical, radiologic, and surgical work-up.

INTERVENTION(S)

Retrospective review of prior medical records and studies.

MAIN OUTCOME MEASURE(S)

Definition of abnormal pelvic anatomy.

RESULT(S)

Five patients from a university-based, reproductive endocrine center were found to have cervical duplication with a longitudinal vaginal septum, uterine septum, and a normal fundus. The patients most often presented initially to their primary obstetrician-gynecologists with symptomatic complaints secondary to their vaginal septums. Diagnoses were obtained with physical examinations, ultrasound imaging, hysterosalpingograms, magnetic resonance imaging, and surgical evaluation.

CONCLUSION(S)

These findings call into question the classic hypothesis of unidirectional (caudal to cranial) müllerian development and supports an alternative embryologic hypothesis of Müller et al., which states that fusion and resorption begins at the isthmus and proceeds simultaneously in both the cranial and caudad directions. The high number of cases reported here might be due to the increased accessibility and accuracy of such imaging modalities as magnetic resonance imaging. These patients will be followed longitudinally so that it can be determined whether this anomaly affects fertility and so that the optimal treatment plans can be developed.

Agenesis of the bladder with solitary renal dysplasia: management of a challenging condition

Bladder agenesis is an extremely rare congenital anomaly. We report a case of bladder agenesis in a newborn girl with a prolapsing ectopic ureter and solitary dysplastic kidney. The classification of this disorder and the management of this patient are reviewed.

Double cervix with bilateral and synchronous HSIL associated with different high-risk HPV types. A case report

BACKGROUND

High grade squamous intraepithelial lesion (HSIL) of the cervix is well known to be associated with human papillomavirus (HPV) infection. HSIL and invasive carcinomas occurring synchronously in genital malformations, such as a double cervix, have been reported. It has been postulated that the field effect phenomenon of HPV infection is responsible for this synchronous infection. However, there is no information in the literature on the specific types of HPV causing the concomitant lesions in cases with a double cervix.

CASE

A 33-year-old nulligravida with a double cervix and a single uterine corpus was diagnosed with bilateral HSIL on Papanicolaou-stained ThinPrep slides (Cytyc Corp., Boxborough, Massachusetts, U.S.A.). A bilateral loop electrosurgical excision procedure cone biopsy revealed HSIL involving both cervices. DNA extracted from the HSIL lesions was analyzed by a polymerase chain reaction-based assay for the presence of HPV. High-risk HPV type 33 was identified in the right cervix, while HPV type 35 was present in the left.

CONCLUSION

Demonstration of high-risk HPV types bilaterally supported the etiologic role of HPV infection in the synchronous and bilateral occurrence of HSIL in this case of a double cervix. The HPV types were different in the right and left cervices.

Septate uterus with cervical duplication: rethinking the development of müllerian anomalies

We present a case of a septate uterus with duplication of the cervix and a vaginal septum, which challenges the embryologic concept of unidirectional caudad to cephalad müllerian ducts fusion. This unique case is, to the best of our knowledge, the seventh reported case of this müllerian anomaly. It challenges the classic theory of unidirectional caudad to cephalad fusion of the müllerian ducts, and might be additional evidence to support the hypothesis suggested by Musset et al. Accurate diagnosis and reports of such cases are important not only for the benefit of treatment, but to reflect the true incidence of this anomaly, and consolidate the embryologic concept.