A novel approach to cervical reconstruction using vaginal mucosa-lined polytetrafluoroethylene graft in congenital agenesis of the cervix

Biodegradable Multi-layered Silk Fibroin-PCL Stent for the Management of Cervical Atresia: In Vitro Cytocompatibility and Extracellular Matrix Remodeling In Vivo

Cervical atresia is a rare congenital Müllerian duct anomaly that manifests as the absence or deformed nonfunctional presence of the cervix. Herein, a multi-layered biodegradable stent is fabricated using a homogeneous blend of silk fibroin with polycaprolactone using hexafluoroisopropanol as a common solution. Briefly, a concentric cylinder of 3D honeycomb layer is sandwiched within electrospun sheets for fixing at the cervico-uterine junction to pave the way of cervical reconstruction. An average length of 40 mm with 3 mm diameter is fabricated for the hybrid stent design. SEM evidences an evenly distributed pore architecture of the electrospun layer, and mechanical characterization of stent reveals a tensile strength of 1.7 ± 0.2 MPa, with a Young's modulus of 5.9 ± 0.1 MPa. Physico-chemical characterization confirms the presence of silk fibroin and poly caprolactone within the engineered stent. Following 14 days of pepsin enzymatic degradation, 18% degradation and a contact angle measurement of 97° are observed. In vitro cytocompatibility studies are performed using site-specific primary human cervical squamous, columnar epithelial cells, and human endometrial stromal cells. The study demonstrates non-cytotoxic cells' viability (no significant toxicity), improved cell anchoring, adherence among the stent layers, and proliferation in the 3D microenvironment. Furthermore, in vivo subcutaneous studies in the rodent model indicate that the implanted stent undergoes constructive remodeling, neo-tissue creation, neo-vasculature formation, and re-epithelialization while maintaining patency for 2 months.

Innovating the conservative management of isolated cervical aplasia

Isolated cervical aplasia (ESHRE/ESGE U0C4V0) is a rare condition with an incidence of approximately 1:100,000 births.This congenital malformation of the female genital tract represents an impairment of the outflow tract and is an inevitable cause of infertility. Patients usually present with pelvic pain or haematometra and surgical treatment is needed. Conservative management is the first line of approach, allowing for future fertility. However, complications are not negligible. Choosing the best surgical technique remains controversial as few follow-up studies have been published.We describe a case report of isolated cervical aplasia diagnosed in a 16-year-old patient, managed by a canalisation procedure using a Foley catheter. Following failure of this approach, a levonorgestrel intrauterine system was inserted, which remained efficient after 4 years.This case adds to the few reports of success in the management of this challenging clinical entity and might guide clinicians to avoid non-conservative approaches in young patients.

Functional and Reproductive Outcomes Following Surgical Management of Congenital Anomalies of the Cervix: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to evaluate surgical treatment for malformations of the cervix in terms of short- and long-term postoperative function and relevant reproductive outcomes.

DATA SOURCES

International Prospective Register of Systematic Reviews (ID No CRD42019128899). Electronic databases were searched for eligible studies up to October 2019 on Medline/PubMed (1966-2019), Scopus/Elsevier (1950-2019), and Google Scholar (up to 2019). Search terms included "congenital cervical malformations/anomalies," "uterocervical aplasia/dysgenesis/agenesis," "cervical aplasia/dysgenesis/ agenesis," "müllerian anomalies/dysgenesis/agenesis," "utero-vaginal anastomosis," "cervical reconstruction," "uterocervical reconstruction/canalization," "cervical canalization," "reproductive/pregnancy/functional outcome," "menstruation," "pregnancy," and "regular periods."

METHODS OF STUDY SELECTION

Studies were chosen and included with clear description of preoperative diagnosis via sonography, magnetic resonance imaging, and surgical confirmation; assessment and clear description of gynecologic anatomy and any concomitant anomalies; meticulous description of the operative technique; follow-up of at least 6 weeks postoperatively; and postoperative end points including menstrual and reproductive outcomes. We included randomized controlled trials, case-control studies (both prospective and retrospective), and case reports. Data registries, studies without clearly described primary or secondary outcomes, and studies not in the English language were excluded from the analyses.

TABULATION, INTEGRATION, AND RESULTS

The literature search returned 745 studies; 546 records were initially excluded (397 not related to the topic, 15 not related to humans, 134 non-English language); 111 full-text articles were further excluded (patients underwent hysterectomy or no surgery); 88 studies with a total of 249 patients were suitable for analysis. Almost all patients had preoperative amenorrhea (248/249, 99.6%). Postoperatively, of 249 patients, resolution of menstruation occurred in 228 patients (91.6%), and hysterectomy was performed in 22 patients (8.8%); overall, there were 30 (12.0%) conceptions that resulted in 27 (10.8%) viable and 24 (9.6%) term pregnancies. Indications for hysterectomy were stenosis of the genital tract and sepsis. Coexisting vaginal agenesis and use of full thickness skin graft for creation of neocervix was associated with negative surgical outcomes.

CONCLUSION

This review suggests that conservative surgical approaches result in better clinical and reproductive outcomes than more aggressive reconstructive surgeries for patients with malformations of the cervix.

Current knowledge about the management of congenital cervical malformations: a literature review

The prevalence of congenital cervical agenesis or dysgenesis ranges from 1/80,000 to 1/100,000, and in about 50% of these cases it coexists with congenital vaginal agenesis. This narrative review summarizes the contemporary knowledge in the field of conservative surgical restoration of the reproductive tract. The management of congenital cervical malformations aims to [1] provide relief from the obstructive symptoms, [2] establish normal sexual function, and [3] preserve the uterus for future fertility. In cases of cervical agenesis and vaginal aplasia, the surgical approach involves the creation of neovagina, the creation of neocervix, and then subsequent restoration of the continuity of the genital tract. In cases where vagina is not congenitally absent, the surgical approach involves either a direct uterovaginal anastomosis or initial creation of neocervix and then subsequent restoration of the continuity of the genital tract. The neocervix can be surgically created with small intestinal submucosa, split-thickness skin graft, full-thickness skin graft, peritoneal flap, or vaginal mucosa lined with a polytetrafluoroethylene graft. Most of the published cases report long-term menstruation and sporadic pregnancies. Conservative surgery of cervical congenital malformations could serve as a first-line treatment. Sexual function and menstruation are established in the majority of patients. Extirpatory surgery may be preserved for surgical failures after initial restoration of the continuity of uterus-cervix-vagina or in cases with more complex anatomy.

Management of Reproductive Tract Anomalies

Reproductive tract malformations are rare in general population but are commonly encountered in women with infertility and recurrent pregnancy loss. Obstructive anomalies present around menarche causing extreme pain and adversely affecting the life of the young women. The clinical signs, symptoms and reproductive problems depend on the anatomic distortions, which may range from congenital absence of the vagina to complex defects in the lateral and vertical fusion of the Müllerian duct system. Identification of symptoms and timely diagnosis are an important key to the management of these defects. Although MRI being gold standard in delineating uterine anatomy, recent advances in imaging technology, specifically 3-dimensional ultrasound, achieve accurate diagnosis. Surgical management depend on the type of anomaly, its complexity and the proper embryological interpretation of the anomaly and involves multiple specialties; thus, patients should be referred to centres with experience in the treatment of complex genital malformations.

A novel approach for congenital absence of the uterine cervix: Office hysteroscopic versapoint canalization using real-time trans-abdominal sonography guidance

Herein, we report a novel technique for cervical agenesis via office hysteroscopy using Versapoint using real-time trans-abdominal sonography guidance. Fourteen days after the canalization procedure, a second hysteroscopy was performed to remove the silicone catheter and insert a Cupper T380a intrauterine device, which aimed to prevent a neocervical canal occlusion. This is the first case report of a patient with congenital cervical agenesis undergoing canalization with Versapoint in an office hysteroscopy; laparoscopy was not performed for assistance.

Laparoscopic-assisted uterovaginal anastomosis for uterine cervix atresia with vaginal aplasia using a silicone stent lined with acellular porcine small intestinal submucosa graft inserted using a 16F Foley catheter

Herein is reported a novel technique for cervical reconstruction of congenital cervicovaginal atresia. The patient was a 16-year-old girl with congenital atresia of the cervix and vagina, didelphic uterus, and right hematosalpinx. At laparoscopic-assisted creation of a neocervix, a silicone stent was inserted using a 16F Foley catheter and lined with an acellular porcine small intestinal submucosa graft under ultrasound guidance. At 3-month clinical follow-up after placement of the stent, the patient had regular menstrual flow. The neocervix was completely mucosalized on the inner surface at 4 months after surgery. There were no complications related to the silicone stent or the cervical stent. Cervical reconstruction using a vaginal mucosa-lined silicone stent is accessible and effective, and provides an alternative option to preserve reproductive potential in patients with cervicovaginal atresia.