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

Management of Cervix Atresia with Hematometra by "Genitoscopic Ultrasound-Guided Cervix Fenestration and Balloon Dilatation": A Novel Approach

Introduction: Cervix atresia causing hematometra usually presents at puberty with cyclic abdominal pain. The management depends upon the type and severity of cervix atresia. We present a novel technique of managing a case of cervix atresia in a 13 years old girl. Case report: A 13 years old girl presented with severe cyclic abdominal pain. Examination revealed normal external genitalia with a palpable tender mass in the suprapubic area. Ultrasonography and MRI suggested a large hematometra with a 1.5 cm long cervix atresia. Vaginoscopy performed under anesthesia showed a normal-looking vagina and a blind cervix. During vaginoscopy and dynamic ultrasound (US) guidance, a spinal needle was passed through the vagina and center of the atretic cervix into the uterine cavity containing the hemolyzed blood. Aspiration of the hemolyzed blood and US visualization confirmed the location of the needle in the uterine cavity. A three-stage (esophageal) balloon dilator was passed over a guidewire through the atretic area. The balloon dilator was dilated up to 10 mm using pressure-controlled dilatation. A satisfactory dilatation was achieved, and all the retained hemolyzed blood was drained through the newly created channel. A size 24 Foleys catheter was retained in the uterine cavity and removed after 1 week. A repeat ultranography before subsequent periods showed a recurrent collection and obliteration of the cervix. US-guided balloon dilatations were repeated. A third dilatation was required after an interval of few months. The child remained well after the third dilatation, having regular periods, and is symptom free at 8 months follow-up, however, may need more sessions of cervix dilatations. Conclusion: Genitoscopic US-guided cervix fenestration and balloon dilatation is an effective technique for treatment of cervix atresia. It is a safe technique, avoids major surgical reconstructions, is a minimally invasive procedure, and can be used in selected cases of cervix atresia.

Cervicovaginal reconstruction with small intestinal submucosa graft in congenital cervicovaginal atresia: A report of 38 cases

OBJECTIVE

To evaluate the quality of life and surgical outcomes in patients with congenital cervicovaginal malformation after cervicovaginal reconstruction.

STUDY DESIGN

Thirty-eight patients diagnosed with congenital cervicovaginal aplasia and underwent cervicovaginal reconstruction using acellular porcine small intestinal submucosa (SIS) grafts were included in the study from January 2012 to December 2019. Of these, twenty-one patients underwent conventional laparoscopy, nine underwent robotic surgery, and eight underwent laparoendoscopic single-site (LESS) surgery. Clinical characteristics, perioperative data, condition of the neovagina and neocevix, post-operation complications, body image, resumption of menstruation, sexual function, and quality of life were assessed.

RESULTS

The average age of the patients was 16.4 ± 5.78 years. The operative procedure lasted 182.29 ± 70.85 min, with a hemoglobin decrease of 12.53 ± 7.55 g/dl. All surgery was completed successfully without complications. The total cost was highest in the robotic surgery group (P < 0.001). The cosmetic scores were significantly higher in the LESS group (P < 0.001). At a median follow-up of 49.79 ± 31.02 months, all patients resumed menstruation, except one patient who underwent hysterectomy due to vaginal obstruction. The average length of neovagina was 8.11 ± 0.75 cm, and the length of the cervix was 1.73 ± 1.00 cm. There were one patient with vaginal stenosis, two patients with cervical occlusion, two patients with cervical stenosis, and six patients with intrauterine device loss. Fourteen patients experienced sexual activity, with the total female sexual function index scores of 26.83 ± 3.49. Six patients had a desire of pregnancy, and one patient had pregnant via assisted-reproduction techniques. No differences in the mean physical component score (PCS) and mental component score (MCS) were identified among three different groups at baseline and all post-surgery time points (P > 0.05), but with the extension of follow-up, both PCS and MCS increased significantly in all groups (P < 0.001).

CONCLUSION

Cervicovaginal reconstruction using an SIS graft is safe and efficient to the management of congenital cervicovaginal atresia whatever by the conventional laparoscopy, robotic surgery or LESS, with good surgical outcomes and high of quality of life.

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.

Regenerative Medicine Approaches in Bioengineering Female Reproductive Tissues

Diseases, disorders, and dysfunctions of the female reproductive tract tissues can result in either infertility and/or hormonal imbalance. Current treatment options are limited and often do not result in tissue function restoration, requiring alternative therapeutic approaches. Regenerative medicine offers potential new therapies through the bioengineering of female reproductive tissues. This review focuses on some of the current technologies that could address the restoration of functional female reproductive tissues, including the use of stem cells, biomaterial scaffolds, bio-printing, and bio-fabrication of tissues or organoids. The use of these approaches could also be used to address issues in infertility. Strategies such as cell-based hormone replacement therapy could provide a more natural means of restoring normal ovarian physiology. Engineering of reproductive tissues and organs could serve as a powerful tool for correcting developmental anomalies. Organ-on-a-chip technologies could be used to perform drug screening for personalized medicine approaches and scientific investigations of the complex physiological interactions between the female reproductive tissues and other organ systems. While some of these technologies have already been developed, others have not been translated for clinical application. The continuous evolution of biomaterials and techniques, advances in bioprinting, along with emerging ideas for new approaches, shows a promising future for treating female reproductive tract-related disorders and dysfunctions.

Laparoscopic uterovaginal anastomosis in patients with congenital cervicovaginal atresia: An institutional experience with 23 patients

OBJECTIVE

To introduce our experience of laparoscopic uterovaginal anastomosis and operative outcomes following this technique and update the clinical management of congenital cervicovaginal atresia.

STUDY DESIGN

Between March 2015 and January 2019, twenty-three patients with congenital cervicovaginal atresia underwent laparoscopic uterovaginal anastomosis and Luohu procedure. Their clinical characteristics, surgical outcomes and follow-up data were retrospectively reviewed.

RESULTS

The mean ± SD age of the cases was 16.4 ± 4.0 (11-26) years. All patients had a history of primary amenorrhea and cyclical abdominal pain, and the average delay in diagnosis from first symptoms was 33.5 ± 38 (1-156) months. Most of the patients had 1-3 cm long vaginal pouch. The operative procedure lasted 125 ± 32 (80-190) min. The average vaginal length at 1 month was 7.9 ± 1.3 (range 6-9) cm. All patients showed resumption of menstruation. The patients were followed for a mean of 27 ± 13 (12-56) months. During the follow-up, cervical stenosis did not occur in any of the cases.

CONCLUSION

Laparoscopic uterovaginal anastomosis with Luohu procedure provided a minimally invasive, safe, and effective surgical option for the patients with congenital cervicovaginal atresia. The technique is uncomplicated, easy to learn and perform, and provides a functional and anatomic satisfactory result. No special surgical instruments are required with this technique.

Novel Method of Cervicoplasty Using Autologous Peritoneum for Cervicovaginal Atresia

Cervicovaginal atresia with a functional uterus is rare. There are no established surgical methods to treat this condition, and only a few reports have been published on surgical techniques. Furthermore, postoperative complications, such as restenosis, often require reoperation. A 19-year-old woman was pointed out cervical hypoplasia and referred to our hospital for further examination and treatment. A pelvic examination revealed that the vagina had a slight recession with a blind end. Transrectal ultrasound and pelvic magnetic resonance imaging revealed congenital vaginal agenesis and cervical hypoplasia. Elective surgery was performed after reshaping the vagina. A radical surgery was performed 10 months later after sufficient self-dilation by using Frank's technique in an outpatient setting. At first, we approached by laparoscopically to correct autologous peritoneum and to bladder detach, then the cervical canal was identified. Next, a skin biopsy punch was used several times to hollow out the cervical tissue to shape and expand the cervical canal. A catheter was then placed in the uterus and autologous peritoneum was wrapped around it and fixed to the cervical canal. The catheter was removed 6 weeks postoperatively, and the patient continued dilating her vagina until she was able to have sexual intercourse, and then stopped the self-dilation. Eight months postoperatively, the patient did not report any menstrual irregularities. It is important to make corrections to prevent restenosis of the vagina and cervical canal and prevent the symptoms from recurring. Make use of autologous peritoneum as graft onto the cervical canal is effective method for the treatment of cervicovaginal atresia.

Bioengineering Strategies to Treat Female Infertility

Bioengineering strategies have demonstrated enormous potential to treat female infertility as a result of chemotherapy, uterine injuries, fallopian tube occlusion, massive intrauterine adhesions, congenital uterine malformations, and hysterectomy. These strategies can be classified into two broad categories as follows: (i) Transplantation of fresh or cryopreserved organs into the host and (ii) tissue engineering approaches that utilize a combination of cells, growth factors, and biomaterials that leverages the body's inherent ability to regenerate/repair reproductive organs. While whole organ transplant has demonstrated success, the source of the organ and the immunogenic effects of allografts remain challenging. Even though tissue engineering strategies can avoid these issues, their feasibilities of creating whole organ constructs are yet to be demonstrated. In this article we summarize the recent advancements in the applications of bioengineering to treat female infertility.